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Strategies for Left Ventricular Assist Device Insertion After the Dor Procedure
Strategies for Left Ventricular Assist Device Insertion After the Dor Procedure Satoru Osaki, MD, PhD, Niloo M. Edwards, MD, and Takushi Kohmoto, MD, PhD Insertion of the inflow cannula of an implantable left ventricular assist device (LVAD) is a surgical challenge in patients who have previously undergone a Dor ventriculoplasty procedure. We report a 54-year-old man who had successful LVAD insertion 18 months after a Dor procedure. We also describe the strategy of LVAD insertion in such patients. J Heart Lung Transplant 2009;28:520 –2. Copyright © 2009 by the International Society for Heart and Lung Transplantation.
The Dor procedure, left ventricular (LV) reconstruction by endoventricular circular patch plasty repair, is now among the surgical therapeutic options for patients with ischemic cardiomyopathy.1 A recent study indicated that the Dor procedure improved LV function and New York Heart Association (NYHA) functional status in congestive heart failure (CHF) patients.2 However, recurrent CHF requiring re-admission was noted in 22% of the cohort within 5 years and a small number of cases required “peri-operative” mechanical support, including a left ventricular assist device (LVAD). LVAD insertion after the Dor procedure is uncommon and surgically challenging when compared with usual LVAD implantation, because apical ventriculotomy, aneurysm resection and patch placement make apical cannulation difficult. In this report we describe a patient with recurrent CHF 18 months after the Dor procedure, who underwent a successful LVAD implantation. CASE REPORT A 54-year-old man had a remote anterior wall myocardial infarction in 1999. In April 2006, he underwent coronary artery bypass grafting to the left anterior descending (LAD) coronary artery, and the Dor procedure at another institution. The LV was reconstructed according to Dor and colleagues,3 with the residual
From the Department of Surgery, Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. Submitted October 31, 2008; revised January 25, 2009; accepted February 10, 2009. Reprint requests: Satoru Osaki, MD, Department of Surgery, Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, H4/337 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792-3236. Telephone: 608-2634071. Fax: 608-263-0547. E-mail: [email protected] Copyright © 2009 by the International Society for Heart and Lung Transplantation. 1053-2498/09/$–see front matter. doi:10.1016/ j.healun.2009.02.004
520
cavity being calibrated using a Fontan stitch and a saline-filled balloon (45 ml/m2 of body surface area). The residual gap was closed with an oval-shaped Dacron patch. After surgery, the patient’s NYHA functional status improved to Class II from Class IV. However, he required repeated re-admissions with progressive CHF. In June 2007, the patient was transferred to our center. An echocardiogram showed LV ejection fraction (LVEF) of 25%, with diffuse hypokinesis, and end-diastolic and end-systolic LV dimensions were 66 and 51 mm, respectively. The patch after LV reconstruction could be seen in the LV apex, as shown in Figure 1. There was mild mitral regurgitation and severe tricuspid regurgitation. Despite 8 weeks of intensive pharmacologic therapy and a biventricular pacemaker insertion, symptoms did not improve and an echocardiogram still revealed severe LV dysfunction and mild LV dilation. LVAD implantation was indicated due to low cardiac output and symptomatic CHF, despite maximal medical therapy. In August 2007, the patient underwent LVAD (HeartMate XVE; Thoratec Corp., Pleasanton, CA) implantation as a bridge to transplant candidate, due to morbid obesity. Tricuspid valve annuloplasty using a 28-mm Carpentier–Edwards rigid ring (Baxter Healthcare Corp., Santa Ana, CA) was also performed due to severe tricuspid regurgitation. The heart was dilated and the saphenous vein graft was patent. Upon examination of the apex, there was a small leakage from an edge of the patch. There were also some organized thrombi in the LV apex, outside of the patch. These thrombi were carefully removed. The patch was then removed, taking care to remove all sutures. Once the patch was removed, an aneurysmal chamber was created. The LVAD inflow cuff was then secured to the LV apex with 2-0 Tevdek pledgeted sutures (Figure 2). The inflow cannula thus lay within the original aneurysmal chamber (Figure 3). The outflow graft was sewn to the ascending aorta. LVAD flows were approximately 5.0 liters/min. The patient’s postoperative course was complicated by ileus, but he was
The Journal of Heart and Lung Transplantation Volume 28, Number 5
Figure 1. Pre-operative transesophageal echocardiogram using the 4-chamber view, showing the patch after the Dor procedure in the LV apex (arrow).
discharged from the hospital 28 days after surgery with LVAD support. Unfortunately, he died of ischemic bowel 74 days after LVAD implantation without being listed for heart transplantation due to no change in weight. DISCUSSION LVAD implantation after the Dor procedure is uncommon and surgically challenging. According to the RESTORE report, LVAD was implanted in 0.7% of patients as “peri-operative” mechanical support.2 Williams et al described the LVAD implantation technique after surgical LV restoration and suggested that, for these patients, the crux of the technical component of LVAD implantation is inflow cannula insertion.4 They also cautioned about the location of the new, functional apex being
Figure 2. Intra-operative photograph demonstrating the existing apex hole created by the first Dor operation after removing the patch and clots.
Osaki et al.
521
Figure 3. Post-operative transesophageal echocardiogram demonstrating appropriate LV size and cannulation of LVAD inflow.
more inferolateral to the native apex, and also the direction of the inflow cannula, which should be toward the mitral valve and away from the septum. Our surgical strategies for inflow cannula insertion are shown in Figure 4. In this case, we were able to implement direct LV cannulation by utilizing the existing LV apex ventriculotomy created by the prior operation, because there was enough LV apical scar tissue and LV cavity remaining. The size of the ventriculotomy was suitable for this cannula insertion, and the wall thickness of the ventricular edge was sufficient to sew this cannula (Figure 4A). If the native ventricular edge is not appropriate for sewing a cannula and the remaining LV cavity is large enough to prevent suctioning of LVAD inflow cannula, then the inflow cuff can be directly anastomosed to the patch (Figure 4B). Otherwise, if the remaining LV cavity is too small for the LVAD inflow cannula, then left atrial inflow cannulation is the only option (Figure 4C). There are various surgical options for treatment of recurrent CHF after the Dor procedure. Orthotopic heart transplantation is a reliable option if patients meet the criteria. However, in the present case, although the patient was 54 years old, he was not an immediate transplant candidate because of morbid obesity (⬎140% of his ideal weight). Thus, LVAD implantation was indicated as bridge to transplant candidacy. Koch et al reported 2 successful cases of re-do LV surgical reconstruction after previous LV aneurysmectomy.5 For our patient, however, due to diffuse LV hypokinesis, mild LV dilation and mild mitral regurgitation, we decided that LVAD insertion would be beneficial. In conclusion, we have described successful HeartMate XVE LVAD implantation in a patient with recurrent CHF 18 months after the Dor procedure. Our experience indicates that removal of the patch and the use of the existing apex hole created by the Dor
522
Osaki et al.
The Journal of Heart and Lung Transplantation May 2009
Figure 4. Surgical strategies for LVAD inflow cannula insertion after the Dor procedure. (A) Direct LV cannulation utilizing the existing apex hole created by the prior operation, when enough LV apical scar tissue and LV cavity remain. (B) Direct anastomosis of the inflow cuff to the patch, when enough LV cavity remains but the native ventricular edge is inappropriate for sewing. (C) Left atrial inflow cannulation, when the remaining LV cavity is too small for the inflow cannula.
procedure are feasible for LVAD inflow cannulation if the quality of remaining apical myocardium is adequate for sewing and the remaining LV cavity is large enough to prevent inflow cannula obstruction. REFERENCES 1. Dor V, Di DM, Sabatier M, et al. Left ventricular reconstruction by endoventricular circular patch plasty repair: a 17-year experience. Semin Thorac Cardiovasc Surg 2001;13:435– 47. 2. Athanasuleas CL, Buckberg GD, Stanley AW, et al. Surgical ventricular restoration in the treatment of congestive heart failure due to
post-infarction ventricular dilation. J Am Coll Cardiol 2004;44: 1439 – 45. 3. Dor V, Sabatier M, Di DM, et al. Late hemodynamic results after left ventricular patch repair associated with coronary grafting in patients with postinfarction akinetic or dyskinetic aneurysm of the left ventricle. J Thorac Cardiovasc Surg 1995;110:1291–9. 4. Williams J, Conte J. Ventricular assist device placement following surgical ventricular restoration. Interact Cardiovasc Thorac Surg 2006;5:90 –1. 5. Koch AD, Holman ER, Versteegh MI, et al. Reconstruction of the left ventricle after previous aneurysmectomy. Ann Thorac Surg 2006;81:1495–7.
The Dor procedure, left ventricular (LV) reconstruction by endoventricular circular patch plasty repair, is now among the surgical therapeutic options for patients with ischemic cardiomyopathy.1 A recent study indicated that the Dor procedure improved LV function and New York Heart Association (NYHA) functional status in congestive heart failure (CHF) patients.2 However, recurrent CHF requiring re-admission was noted in 22% of the cohort within 5 years and a small number of cases required “peri-operative” mechanical support, including a left ventricular assist device (LVAD). LVAD insertion after the Dor procedure is uncommon and surgically challenging when compared with usual LVAD implantation, because apical ventriculotomy, aneurysm resection and patch placement make apical cannulation difficult. In this report we describe a patient with recurrent CHF 18 months after the Dor procedure, who underwent a successful LVAD implantation. CASE REPORT A 54-year-old man had a remote anterior wall myocardial infarction in 1999. In April 2006, he underwent coronary artery bypass grafting to the left anterior descending (LAD) coronary artery, and the Dor procedure at another institution. The LV was reconstructed according to Dor and colleagues,3 with the residual
From the Department of Surgery, Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. Submitted October 31, 2008; revised January 25, 2009; accepted February 10, 2009. Reprint requests: Satoru Osaki, MD, Department of Surgery, Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, H4/337 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792-3236. Telephone: 608-2634071. Fax: 608-263-0547. E-mail: [email protected] Copyright © 2009 by the International Society for Heart and Lung Transplantation. 1053-2498/09/$–see front matter. doi:10.1016/ j.healun.2009.02.004
520
cavity being calibrated using a Fontan stitch and a saline-filled balloon (45 ml/m2 of body surface area). The residual gap was closed with an oval-shaped Dacron patch. After surgery, the patient’s NYHA functional status improved to Class II from Class IV. However, he required repeated re-admissions with progressive CHF. In June 2007, the patient was transferred to our center. An echocardiogram showed LV ejection fraction (LVEF) of 25%, with diffuse hypokinesis, and end-diastolic and end-systolic LV dimensions were 66 and 51 mm, respectively. The patch after LV reconstruction could be seen in the LV apex, as shown in Figure 1. There was mild mitral regurgitation and severe tricuspid regurgitation. Despite 8 weeks of intensive pharmacologic therapy and a biventricular pacemaker insertion, symptoms did not improve and an echocardiogram still revealed severe LV dysfunction and mild LV dilation. LVAD implantation was indicated due to low cardiac output and symptomatic CHF, despite maximal medical therapy. In August 2007, the patient underwent LVAD (HeartMate XVE; Thoratec Corp., Pleasanton, CA) implantation as a bridge to transplant candidate, due to morbid obesity. Tricuspid valve annuloplasty using a 28-mm Carpentier–Edwards rigid ring (Baxter Healthcare Corp., Santa Ana, CA) was also performed due to severe tricuspid regurgitation. The heart was dilated and the saphenous vein graft was patent. Upon examination of the apex, there was a small leakage from an edge of the patch. There were also some organized thrombi in the LV apex, outside of the patch. These thrombi were carefully removed. The patch was then removed, taking care to remove all sutures. Once the patch was removed, an aneurysmal chamber was created. The LVAD inflow cuff was then secured to the LV apex with 2-0 Tevdek pledgeted sutures (Figure 2). The inflow cannula thus lay within the original aneurysmal chamber (Figure 3). The outflow graft was sewn to the ascending aorta. LVAD flows were approximately 5.0 liters/min. The patient’s postoperative course was complicated by ileus, but he was
The Journal of Heart and Lung Transplantation Volume 28, Number 5
Figure 1. Pre-operative transesophageal echocardiogram using the 4-chamber view, showing the patch after the Dor procedure in the LV apex (arrow).
discharged from the hospital 28 days after surgery with LVAD support. Unfortunately, he died of ischemic bowel 74 days after LVAD implantation without being listed for heart transplantation due to no change in weight. DISCUSSION LVAD implantation after the Dor procedure is uncommon and surgically challenging. According to the RESTORE report, LVAD was implanted in 0.7% of patients as “peri-operative” mechanical support.2 Williams et al described the LVAD implantation technique after surgical LV restoration and suggested that, for these patients, the crux of the technical component of LVAD implantation is inflow cannula insertion.4 They also cautioned about the location of the new, functional apex being
Figure 2. Intra-operative photograph demonstrating the existing apex hole created by the first Dor operation after removing the patch and clots.
Osaki et al.
521
Figure 3. Post-operative transesophageal echocardiogram demonstrating appropriate LV size and cannulation of LVAD inflow.
more inferolateral to the native apex, and also the direction of the inflow cannula, which should be toward the mitral valve and away from the septum. Our surgical strategies for inflow cannula insertion are shown in Figure 4. In this case, we were able to implement direct LV cannulation by utilizing the existing LV apex ventriculotomy created by the prior operation, because there was enough LV apical scar tissue and LV cavity remaining. The size of the ventriculotomy was suitable for this cannula insertion, and the wall thickness of the ventricular edge was sufficient to sew this cannula (Figure 4A). If the native ventricular edge is not appropriate for sewing a cannula and the remaining LV cavity is large enough to prevent suctioning of LVAD inflow cannula, then the inflow cuff can be directly anastomosed to the patch (Figure 4B). Otherwise, if the remaining LV cavity is too small for the LVAD inflow cannula, then left atrial inflow cannulation is the only option (Figure 4C). There are various surgical options for treatment of recurrent CHF after the Dor procedure. Orthotopic heart transplantation is a reliable option if patients meet the criteria. However, in the present case, although the patient was 54 years old, he was not an immediate transplant candidate because of morbid obesity (⬎140% of his ideal weight). Thus, LVAD implantation was indicated as bridge to transplant candidacy. Koch et al reported 2 successful cases of re-do LV surgical reconstruction after previous LV aneurysmectomy.5 For our patient, however, due to diffuse LV hypokinesis, mild LV dilation and mild mitral regurgitation, we decided that LVAD insertion would be beneficial. In conclusion, we have described successful HeartMate XVE LVAD implantation in a patient with recurrent CHF 18 months after the Dor procedure. Our experience indicates that removal of the patch and the use of the existing apex hole created by the Dor
522
Osaki et al.
The Journal of Heart and Lung Transplantation May 2009
Figure 4. Surgical strategies for LVAD inflow cannula insertion after the Dor procedure. (A) Direct LV cannulation utilizing the existing apex hole created by the prior operation, when enough LV apical scar tissue and LV cavity remain. (B) Direct anastomosis of the inflow cuff to the patch, when enough LV cavity remains but the native ventricular edge is inappropriate for sewing. (C) Left atrial inflow cannulation, when the remaining LV cavity is too small for the inflow cannula.
procedure are feasible for LVAD inflow cannulation if the quality of remaining apical myocardium is adequate for sewing and the remaining LV cavity is large enough to prevent inflow cannula obstruction. REFERENCES 1. Dor V, Di DM, Sabatier M, et al. Left ventricular reconstruction by endoventricular circular patch plasty repair: a 17-year experience. Semin Thorac Cardiovasc Surg 2001;13:435– 47. 2. Athanasuleas CL, Buckberg GD, Stanley AW, et al. Surgical ventricular restoration in the treatment of congestive heart failure due to
post-infarction ventricular dilation. J Am Coll Cardiol 2004;44: 1439 – 45. 3. Dor V, Sabatier M, Di DM, et al. Late hemodynamic results after left ventricular patch repair associated with coronary grafting in patients with postinfarction akinetic or dyskinetic aneurysm of the left ventricle. J Thorac Cardiovasc Surg 1995;110:1291–9. 4. Williams J, Conte J. Ventricular assist device placement following surgical ventricular restoration. Interact Cardiovasc Thorac Surg 2006;5:90 –1. 5. Koch AD, Holman ER, Versteegh MI, et al. Reconstruction of the left ventricle after previous aneurysmectomy. Ann Thorac Surg 2006;81:1495–7.