ASAIO Journal 2015
Case Reports
Minimally Invasive Right Ventricular Assist Device Implantation in a Patient with HeartWare left ventricular Assist Device Bujar Maxhera,* Alexander Albert,* Ralf Westenfeld,†, Udo Boeken,* Artur Lichtenberg,* and Diyar Saeed*
Many centers reported positive outcome after left ventricular assist devices (LVADs) implantation using a minimally invasive approach. The main drawback of this minimally invasive approach is the feasibility of right ventricular assist device (RVAD) implantation with direct cannulation of the pulmonary artery in cases of perioperative right ventricular failure (RVF). We report our experience with a 41-year-old male patient who was supported with a temporary RVAD using J-sternotomy approach for RVF after LVAD implantation. No technical issue was encountered, and the patient’s condition stabilized immediately after RVAD implantation. However, several days later, the patient developed severe septic shock caused by pneumonia and died on the postoperative day 15 after RVAD implantation. ASAIO Journal 2015; 61:e42–e43.
hypertension, hyperlipidemia, diabetes mellitus, obstructive sleep apnea syndrome, and chronic renal insufficiency. The patient was on renal dialysis before the LVAD surgery. A minimally invasive HeartWare HVAD (HeartWare, Framingham, MA) implantation was performed using left thoracotomy and J-sternotomy approach (right third intercostal space) as a bridge-to-heart transplantation. The initial postoperative course was uneventful, and the patient was extubated 6 hours after the surgery. On the second postoperative day, the patient developed malignant ventricular arrhythmias and signs of RVF. Multiple defibrillations failed to establish sinus rhythm. Therefore, an emergent RVAD implantation was indicated. We sought to use the standard temporary RVAD implantation technique that is used at our institution for patients with RVF.3 However, in this case, we avoided full sternotomy, and the previous J-sternotomy approach was used. Several pericardial traction sutures on the left and cranial site of the pulmonary artery were applied to expose the pulmonary artery. After exposing and side clamping of the pulmonary artery, an 8 mm Dacron graft was sewn in an end-to-side fashion to the pulmonary artery using 5-0 Prolene sutures (Figure 1). An incision was then made in the subxiphoid area about 4–5 cm distal from xiphoid process. The Dacron graft was pulled through this exit, where the RVAD outflow cannula was inserted (Figure 2). It is noteworthy that the RVAD outflow cannula should be inserted deep enough to avoid kinking of the outflow graft at the exit site. A temporary left atrial pressure line was also inserted to directly monitor left atrial pressure. The inflow cannula was inserted percutaneously via the right femoral vein into the right atrium using the Seldinger technique. The sternum was closed primarily, and the cannulas were connected to a LeviTronix CentriMag
Key Words: VAD, RVAD, minimal invasive
The implantation technique of the mechanical circulatory
support systems has evolved considerably during the past few years. Many centers shifted from using full sternotomy approach to other, less-invasive methods with promising outcome.1,2 However, apart from technical issues associated with these less-invasive techniques, another main limitation includes the feasibility of right ventricular assist device (RVAD) implantation with direct cannulation of the pulmonary artery in cases of perioperative right ventricular failure (RVF). To our knowledge, we report the first published report of a patient who was supported with an RVAD using J-sternotomy approach for RVF after left ventricular assist device (LVAD) implantation. Case Report A 41-year-old morbidly obese male patient with dilative cardiomyopathy and severely depressed left ventricular ejection fraction of 10% was admitted to our institution for LVAD implantation. His medical history was significant for From the *Clinic for Cardiovascular Surgery, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany; and †Clinic for Cardiology, Pneumology and Angiology, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany. Submitted for consideration October 2014; accepted for publication in revised form February 2015. This paper was presented at the International Society for Heart and Lung Transplantation, 34th Anniversary Meeting, San Diego, CA, April 10–13, 2014. Disclosure: The authors have no conflicts of interest to report. Correspondence: Diyar Saeed, Clinic for Cardiovascular Surgery, University Hospital of Düsseldorf, Heinrich-Heine University, Moorenstraße 5, 40225 Düsseldorf, Germany. Email: diyar.saeed@med. uni-duesseldorf.de. Copyright © 2015 by the American Society for Artificial Internal Organs
Figure 1. The outflow grafts of the left and right ventricular assist devices. LVAD, left ventricular assist device; RVAD, right ventricular assist device.
DOI: 10.1097/MAT.0000000000000250
e42
Copyright © American Society of Artificial Internal Organs. Unauthorized reproduction of this article is prohibited.
e43
MINIMAL INVASIVE RVAD IMPLANTATION
cannulation of the pulmonary artery compared with peripheral venoarterial extracorporeal life support.5 Alternatively, two other novel percutaneous techniques have been described for RVAD implantation.6,7 The first one was reported by Columbia University colleagues.6 However, the limited number of patients and experience with this technique precludes a wide application of this technology for a longer duration at this stage of development. Furthermore, Cheung et al.7 recently published their experience with Impella right direct and right peripheral temporary ventricular assist devices (Abiomed, Danvers, MA). The main advantage of Impella use is the possibility of peripheral application without sternotomy in cases of right peripheral Impella (merely three patients in the aforementioned study). However, main limitation includes shorter support duration.
Figure 2. The left and right ventricular assist devices in situ. The RVAD inflow cannula is inserted percutaneously through the right femoral vein. The RVAD outflow cannula is inserted into a graft, which is attached to the pulmonary artery and passed through a subxihoid exit. RVAD, right ventricular assist device.
circuit (Thoratec Corporation, Pleasanton, CA). Figure 2 shows the patient immediately after surgery with the LVAD/RVAD in place. Based on our previous experience with biventricular support systems,4 the RVAD support was initiated and set at 5 L/min (20% lower than the LVAD flow). The patient’s condition stabilized immediately after surgery. However, several days after RVAD implantation, he developed severe pneumonia and septic shock requiring high-dose vasopressor therapy. Unfortunately, the clinical condition of the patient further deteriorated, and he developed multiple organ failure and died on the postoperative day 17 after LVAD implantation. Discussion This report summarizes the outcome of a male patient who was supported with a temporary RVAD using J-sternotomy approach for RVF after LVAD implantation. Temporary RVAD may be required to support patients with perioperative refractory RVF. Recently, many centers reported positive outcome when the LVAD is implanted using a minimally invasive approach.1,2 The main drawback of these minimally invasive approach is the feasibility of RVAD implantation with direct cannulation of the pulmonary artery in cases of RVF. Therefore, many surgeons tend to use temporary peripheral venoarterial extracorporeal life support in this setting. However, it has been reported in a recent study that a better outcome and lower thromboembolic complication rates are expected if LVAD patients with RVF are supported using RVAD with direct
Conclusion This report shows the feasibility of a minimally invasive temporary RVAD implantation using J-sternotomy approach for patients who have undergone minimal invasive LVAD implantation. The implantation is technically challenging because of limited exposure of the pulmonary artery. Advantages may include possibility of early extubation, extended support duration,8 and reduced risks of resternotomy at the time of RVAD explantation. References 1. Strueber M, Meyer AL, Feussner M, Ender J, Correia JC, Mohr FW: A minimally invasive off-pump implantation technique for continuous-flow left ventricular assist devices: Early experience. J Heart Lung Transplant 33: 851–856, 2014. 2. Haberl T, Riebandt J, Mahr S, et al: Viennese approach to minimize the invasiveness of ventricular assist device implantation. Eur J Cardiothorac Surg 46: 991–6, 2014; discussion 996. 3. Saeed D, Maxhera B, Kamiya H, Lichtenberg A, Albert A: Alternative right ventricular assist device implantation technique for patients with perioperative right ventricular failure. J Thorac Cardiovasc Surg 149: 927–932, 2015. 4. Saeed D, Ootaki Y, Ootaki C, et al: Acute in vivo evaluation of an implantable continuous flow biventricular assist system. ASAIO J 54: 20–24, 2008. 5. Noly PE, Kirsch M, Quessard A, et al: Temporary right ventricular support following left ventricle assist device implantation: A comparison of two techniques. Interact Cardiovasc Thorac Surg 19: 49–55, 2014. 6. Takayama H, Naka Y, Kodali SK, et al: A novel approach to percutaneous right-ventricular mechanical support. Eur J Cardiothorac Surg 41: 423–426, 2012. 7. Cheung AW, White CW, Davis MK, Freed DH: Short-term mechanical circulatory support for recovery from acute right ventricular failure: Clinical outcomes. J Heart Lung Transplant 33: 794–799, 2014. 8. Ortmann P, Saeed D, Lichtenberg A: Case report of extended “temporary” use of Levitronix CentriMag right ventricular assist device. Artif Organs 36: 1072–1073, 2012.
Copyright © American Society of Artificial Internal Organs. Unauthorized reproduction of this article is prohibited.
Case Reports
Minimally Invasive Right Ventricular Assist Device Implantation in a Patient with HeartWare left ventricular Assist Device Bujar Maxhera,* Alexander Albert,* Ralf Westenfeld,†, Udo Boeken,* Artur Lichtenberg,* and Diyar Saeed*
Many centers reported positive outcome after left ventricular assist devices (LVADs) implantation using a minimally invasive approach. The main drawback of this minimally invasive approach is the feasibility of right ventricular assist device (RVAD) implantation with direct cannulation of the pulmonary artery in cases of perioperative right ventricular failure (RVF). We report our experience with a 41-year-old male patient who was supported with a temporary RVAD using J-sternotomy approach for RVF after LVAD implantation. No technical issue was encountered, and the patient’s condition stabilized immediately after RVAD implantation. However, several days later, the patient developed severe septic shock caused by pneumonia and died on the postoperative day 15 after RVAD implantation. ASAIO Journal 2015; 61:e42–e43.
hypertension, hyperlipidemia, diabetes mellitus, obstructive sleep apnea syndrome, and chronic renal insufficiency. The patient was on renal dialysis before the LVAD surgery. A minimally invasive HeartWare HVAD (HeartWare, Framingham, MA) implantation was performed using left thoracotomy and J-sternotomy approach (right third intercostal space) as a bridge-to-heart transplantation. The initial postoperative course was uneventful, and the patient was extubated 6 hours after the surgery. On the second postoperative day, the patient developed malignant ventricular arrhythmias and signs of RVF. Multiple defibrillations failed to establish sinus rhythm. Therefore, an emergent RVAD implantation was indicated. We sought to use the standard temporary RVAD implantation technique that is used at our institution for patients with RVF.3 However, in this case, we avoided full sternotomy, and the previous J-sternotomy approach was used. Several pericardial traction sutures on the left and cranial site of the pulmonary artery were applied to expose the pulmonary artery. After exposing and side clamping of the pulmonary artery, an 8 mm Dacron graft was sewn in an end-to-side fashion to the pulmonary artery using 5-0 Prolene sutures (Figure 1). An incision was then made in the subxiphoid area about 4–5 cm distal from xiphoid process. The Dacron graft was pulled through this exit, where the RVAD outflow cannula was inserted (Figure 2). It is noteworthy that the RVAD outflow cannula should be inserted deep enough to avoid kinking of the outflow graft at the exit site. A temporary left atrial pressure line was also inserted to directly monitor left atrial pressure. The inflow cannula was inserted percutaneously via the right femoral vein into the right atrium using the Seldinger technique. The sternum was closed primarily, and the cannulas were connected to a LeviTronix CentriMag
Key Words: VAD, RVAD, minimal invasive
The implantation technique of the mechanical circulatory
support systems has evolved considerably during the past few years. Many centers shifted from using full sternotomy approach to other, less-invasive methods with promising outcome.1,2 However, apart from technical issues associated with these less-invasive techniques, another main limitation includes the feasibility of right ventricular assist device (RVAD) implantation with direct cannulation of the pulmonary artery in cases of perioperative right ventricular failure (RVF). To our knowledge, we report the first published report of a patient who was supported with an RVAD using J-sternotomy approach for RVF after left ventricular assist device (LVAD) implantation. Case Report A 41-year-old morbidly obese male patient with dilative cardiomyopathy and severely depressed left ventricular ejection fraction of 10% was admitted to our institution for LVAD implantation. His medical history was significant for From the *Clinic for Cardiovascular Surgery, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany; and †Clinic for Cardiology, Pneumology and Angiology, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany. Submitted for consideration October 2014; accepted for publication in revised form February 2015. This paper was presented at the International Society for Heart and Lung Transplantation, 34th Anniversary Meeting, San Diego, CA, April 10–13, 2014. Disclosure: The authors have no conflicts of interest to report. Correspondence: Diyar Saeed, Clinic for Cardiovascular Surgery, University Hospital of Düsseldorf, Heinrich-Heine University, Moorenstraße 5, 40225 Düsseldorf, Germany. Email: diyar.saeed@med. uni-duesseldorf.de. Copyright © 2015 by the American Society for Artificial Internal Organs
Figure 1. The outflow grafts of the left and right ventricular assist devices. LVAD, left ventricular assist device; RVAD, right ventricular assist device.
DOI: 10.1097/MAT.0000000000000250
e42
Copyright © American Society of Artificial Internal Organs. Unauthorized reproduction of this article is prohibited.
e43
MINIMAL INVASIVE RVAD IMPLANTATION
cannulation of the pulmonary artery compared with peripheral venoarterial extracorporeal life support.5 Alternatively, two other novel percutaneous techniques have been described for RVAD implantation.6,7 The first one was reported by Columbia University colleagues.6 However, the limited number of patients and experience with this technique precludes a wide application of this technology for a longer duration at this stage of development. Furthermore, Cheung et al.7 recently published their experience with Impella right direct and right peripheral temporary ventricular assist devices (Abiomed, Danvers, MA). The main advantage of Impella use is the possibility of peripheral application without sternotomy in cases of right peripheral Impella (merely three patients in the aforementioned study). However, main limitation includes shorter support duration.
Figure 2. The left and right ventricular assist devices in situ. The RVAD inflow cannula is inserted percutaneously through the right femoral vein. The RVAD outflow cannula is inserted into a graft, which is attached to the pulmonary artery and passed through a subxihoid exit. RVAD, right ventricular assist device.
circuit (Thoratec Corporation, Pleasanton, CA). Figure 2 shows the patient immediately after surgery with the LVAD/RVAD in place. Based on our previous experience with biventricular support systems,4 the RVAD support was initiated and set at 5 L/min (20% lower than the LVAD flow). The patient’s condition stabilized immediately after surgery. However, several days after RVAD implantation, he developed severe pneumonia and septic shock requiring high-dose vasopressor therapy. Unfortunately, the clinical condition of the patient further deteriorated, and he developed multiple organ failure and died on the postoperative day 17 after LVAD implantation. Discussion This report summarizes the outcome of a male patient who was supported with a temporary RVAD using J-sternotomy approach for RVF after LVAD implantation. Temporary RVAD may be required to support patients with perioperative refractory RVF. Recently, many centers reported positive outcome when the LVAD is implanted using a minimally invasive approach.1,2 The main drawback of these minimally invasive approach is the feasibility of RVAD implantation with direct cannulation of the pulmonary artery in cases of RVF. Therefore, many surgeons tend to use temporary peripheral venoarterial extracorporeal life support in this setting. However, it has been reported in a recent study that a better outcome and lower thromboembolic complication rates are expected if LVAD patients with RVF are supported using RVAD with direct
Conclusion This report shows the feasibility of a minimally invasive temporary RVAD implantation using J-sternotomy approach for patients who have undergone minimal invasive LVAD implantation. The implantation is technically challenging because of limited exposure of the pulmonary artery. Advantages may include possibility of early extubation, extended support duration,8 and reduced risks of resternotomy at the time of RVAD explantation. References 1. Strueber M, Meyer AL, Feussner M, Ender J, Correia JC, Mohr FW: A minimally invasive off-pump implantation technique for continuous-flow left ventricular assist devices: Early experience. J Heart Lung Transplant 33: 851–856, 2014. 2. Haberl T, Riebandt J, Mahr S, et al: Viennese approach to minimize the invasiveness of ventricular assist device implantation. Eur J Cardiothorac Surg 46: 991–6, 2014; discussion 996. 3. Saeed D, Maxhera B, Kamiya H, Lichtenberg A, Albert A: Alternative right ventricular assist device implantation technique for patients with perioperative right ventricular failure. J Thorac Cardiovasc Surg 149: 927–932, 2015. 4. Saeed D, Ootaki Y, Ootaki C, et al: Acute in vivo evaluation of an implantable continuous flow biventricular assist system. ASAIO J 54: 20–24, 2008. 5. Noly PE, Kirsch M, Quessard A, et al: Temporary right ventricular support following left ventricle assist device implantation: A comparison of two techniques. Interact Cardiovasc Thorac Surg 19: 49–55, 2014. 6. Takayama H, Naka Y, Kodali SK, et al: A novel approach to percutaneous right-ventricular mechanical support. Eur J Cardiothorac Surg 41: 423–426, 2012. 7. Cheung AW, White CW, Davis MK, Freed DH: Short-term mechanical circulatory support for recovery from acute right ventricular failure: Clinical outcomes. J Heart Lung Transplant 33: 794–799, 2014. 8. Ortmann P, Saeed D, Lichtenberg A: Case report of extended “temporary” use of Levitronix CentriMag right ventricular assist device. Artif Organs 36: 1072–1073, 2012.
Copyright © American Society of Artificial Internal Organs. Unauthorized reproduction of this article is prohibited.
