Ventricular assist device placement following surgical ventricular restoration
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《血管的通路杂志》
Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Blalock 618, 600 North Wolfe Street, Baltimore, MD, USA
Abstract
Surgical ventricular restoration (SVR) is an accepted treatment option for patients with end-stage congestive heart failure (CHF). A minority of these patients will require the placement of a left ventricular assist device (LVAD). We report our operative technique for placement of an LVAD following SVR.
Key Words: Cardiomyopathy; Circulatory assist devices; Heart failure; Heart failure surgery; Left ventricular assist device
1. Introduction
In recent years, surgical ventricular restoration (SVR) has gained popularity as an option for treating patients with congestive heart failure (CHF) [1,2]. A small percentage of these patients will experience deteriorating cardiac function following SVR and may require the placement of a left ventricular assist device (LVAD). LVADs have been shown to improve outcomes in patients with CHF as both a bridge to transplantation and as a destination therapy [3,4].
While the technique for implantation of LVADs has been previously described [5], the technique for LVAD implantation following SVR has never been described. The SVR procedure involves an anterior ventriculotomy and reconstruction which relocates the functional apex of the heart, necessitating an alternative approach to placing the apical left ventricular cannula. We describe our technique for device implantation and discuss the particular anatomic considerations unique to the procedure.
2. Technique
Following re-sternotomy, the heart is exposed and the patient is placed on cardiopulmonary bypass using bicaval venous cannulation. If necessary, femoral-femoral cardiopulmonary bypass may be used. Complete dissection of the heart is critical to the safe implantation of the LVAD. The suture line of the reconstructed anterior wall is identified (Fig. 1). This guides the surgeon to the ‘old’ cardiac apex. The ‘new,’ functional apex, which was created during SVR, is inferolateral to the visible apex. Consequently, the device must be placed in a more inferolateral position. Digital palpation of the decompressed heart may help identify the site.
Once the new apical cannulation site is selected, a vent is placed through a stab wound into the heart (Fig. 2). A ventriculotomy is then made large enough to accommodate the LVAD inflow cannula and the ventricle is inspected. The patch used to reconstruct the anterior wall is a useful landmark (Fig. 3). Pledgetted mattress sutures are then placed around the entire circumference of the ventriculotomy. These sutures are passed through the apical sewing ring and tied. Tying the sutures on the medial (septal) side will help direct the cannula away from the septum. The LVAD apical cannula is then passed through the apical sewing ring and secured with several ties (Fig. 4). After the inflow cannula is placed, implantation of the remainder of the LVAD proceeds in a standard fashion.
3. Discussion
A minority of SVR patients will ultimately require LVAD implantation as a bridge to transplantation or as destination therapy due to progression of heart failure. Implantation in these patients can be tricky. The implantation technique described here may be applied to any device employing apical cannulation. Pumps utilizing trans-diaphragmatic placement of the apical cannula will require some additional consideration in developing the LVAD pocket.
Two key points should be kept in mind. The new, functional apex may be significantly more inferolateral to the natural apex due to the SVR reconstruction, which may make it difficult to determine externally. The previous SVR closure will only help locate the old, natural apex. The second point that should be remembered is that the apical conduit needs to be directed towards the mitral valve and away from the septum. This can be accomplished by keeping the necessary angle in mind while creating the apical ventriculomyotomy and developing the LVAD pocket. In addition, tying the medial and superior sutures first helps hold the apical sewing ring at the correct angle while the remaining sutures are secured.
We have implanted two HeartMate LVADs (Thoratec Corporation, Pleasanton, CA) following SVR using this technique with excellent technical results. The first patient survived over two years with this device. The second patient is currently recovering from his LVAD insertion and has experienced no technical difficulties related to device placement. We have also implanted one Thoratec PVAD (Thoratec Corporation, Pleasanton, CA) with similar results. This technique offers a reliable approach for LVAD implantation following SVR.
Acknowledgements
The authors would like to thank Timothy Phelps for his artistic assistance in the creation of this manuscript. Dr Williams is an Irene Piccinini Investigator in Cardiac Surgery.
References
Athanasuleas CL, Buckberg GD, Stanley AWH. the RESTORE group. Surgical ventricular restoration in the treatment of congestive heart failure due to post-infarction ventricular dilation. Am J Cardiol 2004; 44:1439–1445.
Mickelborough LL, Merchant N, Ivanov J, Rao V, Carson S. Left ventricular reconstruction: early and late results. J Thorac Cardiovasc Surg 2004; 128:27–37.
Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W, Long JW, Ascheim DD, Tierney AR, Levitan RG, Watson JT, Ronan NS, Shapiro PA, Lazar RM, Miller LW, Gupta L, Frazier OH, Desvigne-Nickens P, Oz MC, Poirier VL, Meier P. for the randomized evaluation of mechanical assistance for the treatment of congestive heart failure (REMATCH) study group. Long-term use of a left ventricular assist device for end-stage heart failure. New Engl J Med 2001; 345:201435–1443.
Pennington DG, McBride LR, Peigh PS, Miller LW, Swartz MT. Eight years' experience with bridging to cardiac transplantation. J Thorac Cardiovasc Surg 1994; 107:472–481.
Radavancevic B, Frazier OH, Duncan JM. Implantation technique for the HeartMate left ventricular assist device. J Card Surg 1992; 7:3203–207.(Jason Williams and John C)
Abstract
Surgical ventricular restoration (SVR) is an accepted treatment option for patients with end-stage congestive heart failure (CHF). A minority of these patients will require the placement of a left ventricular assist device (LVAD). We report our operative technique for placement of an LVAD following SVR.
Key Words: Cardiomyopathy; Circulatory assist devices; Heart failure; Heart failure surgery; Left ventricular assist device
1. Introduction
In recent years, surgical ventricular restoration (SVR) has gained popularity as an option for treating patients with congestive heart failure (CHF) [1,2]. A small percentage of these patients will experience deteriorating cardiac function following SVR and may require the placement of a left ventricular assist device (LVAD). LVADs have been shown to improve outcomes in patients with CHF as both a bridge to transplantation and as a destination therapy [3,4].
While the technique for implantation of LVADs has been previously described [5], the technique for LVAD implantation following SVR has never been described. The SVR procedure involves an anterior ventriculotomy and reconstruction which relocates the functional apex of the heart, necessitating an alternative approach to placing the apical left ventricular cannula. We describe our technique for device implantation and discuss the particular anatomic considerations unique to the procedure.
2. Technique
Following re-sternotomy, the heart is exposed and the patient is placed on cardiopulmonary bypass using bicaval venous cannulation. If necessary, femoral-femoral cardiopulmonary bypass may be used. Complete dissection of the heart is critical to the safe implantation of the LVAD. The suture line of the reconstructed anterior wall is identified (Fig. 1). This guides the surgeon to the ‘old’ cardiac apex. The ‘new,’ functional apex, which was created during SVR, is inferolateral to the visible apex. Consequently, the device must be placed in a more inferolateral position. Digital palpation of the decompressed heart may help identify the site.
Once the new apical cannulation site is selected, a vent is placed through a stab wound into the heart (Fig. 2). A ventriculotomy is then made large enough to accommodate the LVAD inflow cannula and the ventricle is inspected. The patch used to reconstruct the anterior wall is a useful landmark (Fig. 3). Pledgetted mattress sutures are then placed around the entire circumference of the ventriculotomy. These sutures are passed through the apical sewing ring and tied. Tying the sutures on the medial (septal) side will help direct the cannula away from the septum. The LVAD apical cannula is then passed through the apical sewing ring and secured with several ties (Fig. 4). After the inflow cannula is placed, implantation of the remainder of the LVAD proceeds in a standard fashion.
3. Discussion
A minority of SVR patients will ultimately require LVAD implantation as a bridge to transplantation or as destination therapy due to progression of heart failure. Implantation in these patients can be tricky. The implantation technique described here may be applied to any device employing apical cannulation. Pumps utilizing trans-diaphragmatic placement of the apical cannula will require some additional consideration in developing the LVAD pocket.
Two key points should be kept in mind. The new, functional apex may be significantly more inferolateral to the natural apex due to the SVR reconstruction, which may make it difficult to determine externally. The previous SVR closure will only help locate the old, natural apex. The second point that should be remembered is that the apical conduit needs to be directed towards the mitral valve and away from the septum. This can be accomplished by keeping the necessary angle in mind while creating the apical ventriculomyotomy and developing the LVAD pocket. In addition, tying the medial and superior sutures first helps hold the apical sewing ring at the correct angle while the remaining sutures are secured.
We have implanted two HeartMate LVADs (Thoratec Corporation, Pleasanton, CA) following SVR using this technique with excellent technical results. The first patient survived over two years with this device. The second patient is currently recovering from his LVAD insertion and has experienced no technical difficulties related to device placement. We have also implanted one Thoratec PVAD (Thoratec Corporation, Pleasanton, CA) with similar results. This technique offers a reliable approach for LVAD implantation following SVR.
Acknowledgements
The authors would like to thank Timothy Phelps for his artistic assistance in the creation of this manuscript. Dr Williams is an Irene Piccinini Investigator in Cardiac Surgery.
References
Athanasuleas CL, Buckberg GD, Stanley AWH. the RESTORE group. Surgical ventricular restoration in the treatment of congestive heart failure due to post-infarction ventricular dilation. Am J Cardiol 2004; 44:1439–1445.
Mickelborough LL, Merchant N, Ivanov J, Rao V, Carson S. Left ventricular reconstruction: early and late results. J Thorac Cardiovasc Surg 2004; 128:27–37.
Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W, Long JW, Ascheim DD, Tierney AR, Levitan RG, Watson JT, Ronan NS, Shapiro PA, Lazar RM, Miller LW, Gupta L, Frazier OH, Desvigne-Nickens P, Oz MC, Poirier VL, Meier P. for the randomized evaluation of mechanical assistance for the treatment of congestive heart failure (REMATCH) study group. Long-term use of a left ventricular assist device for end-stage heart failure. New Engl J Med 2001; 345:201435–1443.
Pennington DG, McBride LR, Peigh PS, Miller LW, Swartz MT. Eight years' experience with bridging to cardiac transplantation. J Thorac Cardiovasc Surg 1994; 107:472–481.
Radavancevic B, Frazier OH, Duncan JM. Implantation technique for the HeartMate left ventricular assist device. J Card Surg 1992; 7:3203–207.(Jason Williams and John C)