How to Do It
419
Minimally Invasive Implantation of Biventricular Assist Devices Tobias Deuse1
Hermann Reichenspurner1
1 Department of Cardiovascular Surgery, University Heart Center
Hamburg, Hamburg, Germany
Address for correspondence Tobias Deuse, MD, Department of Cardiovascular Surgery, UHZ Hamburg, Martinistr. 52 Hamburg 20246, Germany (e-mail: [email protected]).
Abstract Keywords
► circulatory assist devices ► minimally invasive surgery ► heart failure
As minimally invasive left ventricular assist device implantation is being advocated and more widely performed, bailout strategies for postoperative right ventricular failure (RVF) become necessary. We describe our surgical technique for additional right ventricular assist device implantation through a third mini-thoracotomy incision. This new technique allows avoidance of sternotomy even if RVF occurs.
Introduction Minimally invasive implant techniques for left ventricular assist devices (LVADs) have been described and are gaining popularity. While Cheung et al1 and Schmitto et al2 described their techniques using hemi-sternotomy instead of full-sternotomy incisions, Popov et al3 and our group advocate thoracotomy incisions, completely avoiding sternotomy. Anticipated advantages of minimally invasive implant procedures include reduced postoperative bleeding, wound infection, and right ventricular failure (RVF). However, in cases RVF occurs, a bailout strategy for right ventricular support becomes necessary. Here, we describe our technique for additional, minimally invasive, temporary right ventricular assist device (RVAD) implantation.
Technique Minimally invasive HVAD (HeartWare, Framingham, Massachusetts, United States) implantation is performed through two small, bilateral mini-thoracotomy incisions, providing access to the LV apex and the aorta, respectively. To allow inspection of the LV cavity, we use femoro-femoral cardiopulmonary bypass (CPB). Careful CPB weaning is undertaken under transesophageal echo (TEE) control with nitric oxide and milrinone. Should RVF become apparent, RVAD implantation is performed as follows.
received October 11, 2013 accepted after revision December 21, 2013 published online March 3, 2014
A limited left-sided mini-thoracotomy incision is performed in the second intercostal space adjacent to the sternal border. The pericardium overlying the main pulmonary artery (PA) is opened, stay sutures are placed, and a small retractor is inserted (►Fig. 1A). The PA is separated from the aorta and a side-biting clamp is placed. The PA is longitudinally opened over approximately 15 mm. We use a beveled 10 mm Gelweave graft (Vascutek, Renfrewshire, Scotland) as RVAD outflow. The PA anastomosis is performed with 4–0 polypropylene suture using minimally invasive surgical instruments (►Fig. 1B). The graft is de-aired and externalized through a puncture wound in the sixth intercostal space (►Fig. 2) and cannulated with a 22-Fr aortic cannula (Medtronic, Minneapolis, Minnesota, United States). We use the 25-Fr venous femoral cannula (Medtronic) for RVAD inflow, which is routinely used for CPB in minimally invasive cases. A Centrimag (Levitronix, Zurich, Switzerland) or Deltastream (Medos, Stolberg, Germany) is used as temporary extracorporeal assist system. The HVAD and RVAD speeds are set intraoperatively under TEE guidance to provide 4.5 to 5 L/min flow on each device. Patients can be mobilized to the chair and perform simple exercise training while on BVAD support. RVAD weaning is typically started 7 to 14 days after RVAD implantation and is performed step-wise by slowly reducing the RVAD flow. After successful RVAD weaning, the PA graft is accessed through a
© 2014 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1367736. ISSN 0171-6425.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Thorac Cardiovasc Surg 2014;62:419–421.
Minimally Invasive Implantation of Biventricular Assist Devices
Deuse, Reichenspurner
Fig. 1 Third mini-thoracotomy for access to the main PA. A parasternal left-sided mini-thoracotomy is performed in the second intercostal space (white arrow, A). The implanted HVAD is visible through the apical thoracotomy below (black arrow). The PA is partially clamped, incised, and a 10mm graft is anastomosed (B). PA, pulmonary artery.
small skin incision 2 to 3 cm cranial of the skin exit, ligated, cut, and retained in place. The venous cannula is pulled and mild compression is applied. Thus, RVAD explantation is a short, well-tolerated procedure, not requiring chest reopening.
Results This technique was successfully used in two male patients (46 and 56 years old), who had marginal RV function preoperatively. One suffered from biopsy-proven giant cell myocarditis with severely reduced biventricular function. The other
patient was resuscitated after acute myocardial infarction and required emergent extracorporeal membrane oxygenation (ECMO) implantation for cardiogenic shock. After stabilization and neurologic evaluation, he was transferred to the operating room on ECMO. Both patients underwent minimally invasive LVAD implantation and failed an attempt to be weaned from CPB. RVAD implantation was performed as described above. Both patients were successfully weaned from RVAD after 32 and 31 days, respectively, and are currently stable and ambulatory on LVAD support.
Discussion Although registry data analysis has identified RVF requiring biventricular support as the most prominent risk factor for early mortality after LVAD implantation, the prediction of RVF remains challenging. As minimally invasive LVAD implantation is becoming more widespread, bailout strategies for RVF are urgently needed. Although conversion to sternotomy is easy, we believe that avoiding sternotomy is largely beneficial due to the specific complications associated with this incision. Temporary RVAD support can instead be achieved via percutaneous cannula insertion in a hybrid operating room,4 or via an additional mini-thoracotomy, as demonstrated here. Externalization of the PA graft facilitates RVAD explantation,5 which can be performed in mild sedation and without general anesthesia. Although not proven, the retained pericardial geometry around the RV in minimally invasive approaches is expected to support RV function and facilitate RVAD weaning. In conclusion, we describe a surgical technique for minimally invasive RVAD placement after minimally invasive LVAD implantation. This technique adds to our repertoire of strategies to avoid sternotomy. Fig. 2 Immediate postoperative overview. Three mini-thoracotomies are shown in the fifth intercostal space (ICS) left for implantation of the HVAD pump (1) and in the second ICS parasternal on the right (2) and left (3) for access to the ascending aorta and main PA, respectively. The HVAD driveline exit site is shown (4). RVAD inflow is achieved via femoral venous access (not shown) and outflow through a tunneled vascular graft anastomosed to the PA (5). PA, pulmonary artery; RVAD, right ventricular assist device. Thoracic and Cardiovascular Surgeon
Vol. 62
No. 5/2014
References 1 Cheung A, Lamarche Y, Kaan A, et al. Off-pump implantation of the
HeartWare HVAD left ventricular assist device through minimally invasive incisions. Ann Thorac Surg 2011;91(4):1294–1296 2 Schmitto JD, Molitoris U, Haverich A, Strueber M. Implantation of a centrifugal pump as a left ventricular assist device through a novel,
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
420
Minimally Invasive Implantation of Biventricular Assist Devices
421
4 Takayama H, Naka Y, Kodali SK, et al. A novel approach to
percutaneous right-ventricular mechanical support. Eur J Cardiothorac Surg 2012;41(2):423–426 5 Strauch JT, Franke UF, Madershahian N, Wahlers T. Right ventricular assist device implantation—a new transcutaneous approach. Thorac Cardiovasc Surg 2004;52(6):378–379
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
minimized approach: upper hemisternotomy combined with anterolateral thoracotomy. J Thorac Cardiovasc Surg 2012; 143(2):511–513 3 Popov AF, Hosseini MT, Zych B, Simon AR, Bahrami T. HeartWare left ventricular assist device implantation through bilateral anterior thoracotomy. Ann Thorac Surg 2012;93(2):674–676
Deuse, Reichenspurner
Thoracic and Cardiovascular Surgeon
Vol. 62
No. 5/2014
Copyright of Thoracic & Cardiovascular Surgeon is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
419
Minimally Invasive Implantation of Biventricular Assist Devices Tobias Deuse1
Hermann Reichenspurner1
1 Department of Cardiovascular Surgery, University Heart Center
Hamburg, Hamburg, Germany
Address for correspondence Tobias Deuse, MD, Department of Cardiovascular Surgery, UHZ Hamburg, Martinistr. 52 Hamburg 20246, Germany (e-mail: [email protected]).
Abstract Keywords
► circulatory assist devices ► minimally invasive surgery ► heart failure
As minimally invasive left ventricular assist device implantation is being advocated and more widely performed, bailout strategies for postoperative right ventricular failure (RVF) become necessary. We describe our surgical technique for additional right ventricular assist device implantation through a third mini-thoracotomy incision. This new technique allows avoidance of sternotomy even if RVF occurs.
Introduction Minimally invasive implant techniques for left ventricular assist devices (LVADs) have been described and are gaining popularity. While Cheung et al1 and Schmitto et al2 described their techniques using hemi-sternotomy instead of full-sternotomy incisions, Popov et al3 and our group advocate thoracotomy incisions, completely avoiding sternotomy. Anticipated advantages of minimally invasive implant procedures include reduced postoperative bleeding, wound infection, and right ventricular failure (RVF). However, in cases RVF occurs, a bailout strategy for right ventricular support becomes necessary. Here, we describe our technique for additional, minimally invasive, temporary right ventricular assist device (RVAD) implantation.
Technique Minimally invasive HVAD (HeartWare, Framingham, Massachusetts, United States) implantation is performed through two small, bilateral mini-thoracotomy incisions, providing access to the LV apex and the aorta, respectively. To allow inspection of the LV cavity, we use femoro-femoral cardiopulmonary bypass (CPB). Careful CPB weaning is undertaken under transesophageal echo (TEE) control with nitric oxide and milrinone. Should RVF become apparent, RVAD implantation is performed as follows.
received October 11, 2013 accepted after revision December 21, 2013 published online March 3, 2014
A limited left-sided mini-thoracotomy incision is performed in the second intercostal space adjacent to the sternal border. The pericardium overlying the main pulmonary artery (PA) is opened, stay sutures are placed, and a small retractor is inserted (►Fig. 1A). The PA is separated from the aorta and a side-biting clamp is placed. The PA is longitudinally opened over approximately 15 mm. We use a beveled 10 mm Gelweave graft (Vascutek, Renfrewshire, Scotland) as RVAD outflow. The PA anastomosis is performed with 4–0 polypropylene suture using minimally invasive surgical instruments (►Fig. 1B). The graft is de-aired and externalized through a puncture wound in the sixth intercostal space (►Fig. 2) and cannulated with a 22-Fr aortic cannula (Medtronic, Minneapolis, Minnesota, United States). We use the 25-Fr venous femoral cannula (Medtronic) for RVAD inflow, which is routinely used for CPB in minimally invasive cases. A Centrimag (Levitronix, Zurich, Switzerland) or Deltastream (Medos, Stolberg, Germany) is used as temporary extracorporeal assist system. The HVAD and RVAD speeds are set intraoperatively under TEE guidance to provide 4.5 to 5 L/min flow on each device. Patients can be mobilized to the chair and perform simple exercise training while on BVAD support. RVAD weaning is typically started 7 to 14 days after RVAD implantation and is performed step-wise by slowly reducing the RVAD flow. After successful RVAD weaning, the PA graft is accessed through a
© 2014 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1367736. ISSN 0171-6425.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Thorac Cardiovasc Surg 2014;62:419–421.
Minimally Invasive Implantation of Biventricular Assist Devices
Deuse, Reichenspurner
Fig. 1 Third mini-thoracotomy for access to the main PA. A parasternal left-sided mini-thoracotomy is performed in the second intercostal space (white arrow, A). The implanted HVAD is visible through the apical thoracotomy below (black arrow). The PA is partially clamped, incised, and a 10mm graft is anastomosed (B). PA, pulmonary artery.
small skin incision 2 to 3 cm cranial of the skin exit, ligated, cut, and retained in place. The venous cannula is pulled and mild compression is applied. Thus, RVAD explantation is a short, well-tolerated procedure, not requiring chest reopening.
Results This technique was successfully used in two male patients (46 and 56 years old), who had marginal RV function preoperatively. One suffered from biopsy-proven giant cell myocarditis with severely reduced biventricular function. The other
patient was resuscitated after acute myocardial infarction and required emergent extracorporeal membrane oxygenation (ECMO) implantation for cardiogenic shock. After stabilization and neurologic evaluation, he was transferred to the operating room on ECMO. Both patients underwent minimally invasive LVAD implantation and failed an attempt to be weaned from CPB. RVAD implantation was performed as described above. Both patients were successfully weaned from RVAD after 32 and 31 days, respectively, and are currently stable and ambulatory on LVAD support.
Discussion Although registry data analysis has identified RVF requiring biventricular support as the most prominent risk factor for early mortality after LVAD implantation, the prediction of RVF remains challenging. As minimally invasive LVAD implantation is becoming more widespread, bailout strategies for RVF are urgently needed. Although conversion to sternotomy is easy, we believe that avoiding sternotomy is largely beneficial due to the specific complications associated with this incision. Temporary RVAD support can instead be achieved via percutaneous cannula insertion in a hybrid operating room,4 or via an additional mini-thoracotomy, as demonstrated here. Externalization of the PA graft facilitates RVAD explantation,5 which can be performed in mild sedation and without general anesthesia. Although not proven, the retained pericardial geometry around the RV in minimally invasive approaches is expected to support RV function and facilitate RVAD weaning. In conclusion, we describe a surgical technique for minimally invasive RVAD placement after minimally invasive LVAD implantation. This technique adds to our repertoire of strategies to avoid sternotomy. Fig. 2 Immediate postoperative overview. Three mini-thoracotomies are shown in the fifth intercostal space (ICS) left for implantation of the HVAD pump (1) and in the second ICS parasternal on the right (2) and left (3) for access to the ascending aorta and main PA, respectively. The HVAD driveline exit site is shown (4). RVAD inflow is achieved via femoral venous access (not shown) and outflow through a tunneled vascular graft anastomosed to the PA (5). PA, pulmonary artery; RVAD, right ventricular assist device. Thoracic and Cardiovascular Surgeon
Vol. 62
No. 5/2014
References 1 Cheung A, Lamarche Y, Kaan A, et al. Off-pump implantation of the
HeartWare HVAD left ventricular assist device through minimally invasive incisions. Ann Thorac Surg 2011;91(4):1294–1296 2 Schmitto JD, Molitoris U, Haverich A, Strueber M. Implantation of a centrifugal pump as a left ventricular assist device through a novel,
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
420
Minimally Invasive Implantation of Biventricular Assist Devices
421
4 Takayama H, Naka Y, Kodali SK, et al. A novel approach to
percutaneous right-ventricular mechanical support. Eur J Cardiothorac Surg 2012;41(2):423–426 5 Strauch JT, Franke UF, Madershahian N, Wahlers T. Right ventricular assist device implantation—a new transcutaneous approach. Thorac Cardiovasc Surg 2004;52(6):378–379
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
minimized approach: upper hemisternotomy combined with anterolateral thoracotomy. J Thorac Cardiovasc Surg 2012; 143(2):511–513 3 Popov AF, Hosseini MT, Zych B, Simon AR, Bahrami T. HeartWare left ventricular assist device implantation through bilateral anterior thoracotomy. Ann Thorac Surg 2012;93(2):674–676
Deuse, Reichenspurner
Thoracic and Cardiovascular Surgeon
Vol. 62
No. 5/2014
Copyright of Thoracic & Cardiovascular Surgeon is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
