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CASE REPORT DATE ET AL ANEURYSM REPAIR WITH LV
FEATURE ARTICLES
syndrome [1]. Lacking plausible alternative explanations, we contend that the most likely immediate cause of the postoperative circulatory collapse was an anaphylactic reaction to protamine and that the profound LV dysfunction resulted in part from the massive doses of catecholamines administered during resuscitation in the setting of immune-mediated coronary hypersensitivity (Kounis’ syndrome) [5]. In all likelihood, the patient survived the catastrophic hemodynamic collapse thanks to the prompt institution of ECMO. A protamine reaction is defined as an adverse event that occurs within 30 minutes of administration of protamine and in the absence of other plausible explanations; it is associated with profound hypotension, abrupt pulmonary hypertension, noncardiogenic pulmonary edema, or bronchospasm, or a combination [6]. The incidence of protamine-induced hypotension and anaphylaxis is 10.7% [7] and 0.19% [8], respectively. Risk factors include high dose/rapid administration of protamine, fish allergy, vasectomy, and protamine-associated drugs (insulin), none of which applied here [7]. Although the pathogenic mechanism of Takotsubo’s syndrome remains unclear, one theory implicates stressinduced catecholamine release, producing cardiac stunning [1]. In most cases, an emotional or physical stress just before the onset of symptoms can be identified, and the majority of patients are women, suggesting a link to endocrine factors [1]. We postulate that rather than endogenous catecholamines, escalating doses of catecholamines administered in the course of resuscitation for a severe protamine reaction in our patient contributed to the severe LV dysfunction. In a recent report of 9 patients with transient LV dysfunction after intravenous administration of b-adrenergic agonists, 6 patients experienced stress cardiomyopathy after total doses of epinephrine of 1 to 40 mg, and in 3 patients it was triggered by dobutamine infusion during stress echocardiography [4]. However, the sequence of events in our patient (severe protamine reaction prompting administration of high doses of catecholamines followed by severe LV dysfunction) strongly suggests that release of inflammatory mediators triggered by a fulminant immune response to protamine set the stage for coronary hypersensitivity to catecholamines, ultimately potentiating the cardiac insult. Severe allergic and anaphylactic reactions, presumably through mast cell degranulation and coronary vasospasm, can cause angina and myocardial infarction in the absence of underlying coronary artery disease, a clinical scenario that has been termed Kounis’ syndrome [5, 9]. Unlike a typical protamine reaction, in this setting LV dysfunction can be aggravated acutely by administration of epinephrine, the drug of choice for the treatment of anaphylaxis. Thus, once this complication is recognized, strict avoidance of b-adrenergic drugs is critical, and treatment with antihistamines, corticosteroids, and vasodilators (if the blood pressure permits) should begin [9]. ECMO has emerged as a potent therapeutic tool in patients with potentially fatal acute circulatory collapse and allows an excellent short-term outcome in many cases [10]. We believe our patient illustrates this claim. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2014;97:1778–81
In summary, we have reported a case of postoperative Takotsubo’s syndrome in a young woman undergoing mitral valve repair complicated by a severe protamine reaction prompting resuscitation with large doses of catecholamines. Although epinephrine is considered essential in the management of anaphylactic shock, this case highlights the need for high vigilance regarding potentially serious adverse effects of catecholamines administered in this setting. An excellent outcome was made possible by prompt institution of femoral vein–to–femoral artery ECMO.
References 1. Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539–48. 2. Kogan A, Ghosh P, Schwammenthal E, Raanani E. Takotsubo syndrome after cardiac surgery. Ann Thorac Surg 2008;85: 1439–41. 3. Gariboldi V, Jop B, Grisoli D, Jaussaud N, Kerbaul F, Collart F. Takotsubo syndrome after mitral valve replacement for acute endocarditis. Ann Thorac Surg 2011;91:e31–2. 4. Abraham J, Mudd JO, Kapur NK, Klein K, Champion HC, Wittstein IS. Stress cardiomyopathy after intravenous administration of catecholamines and beta-receptor agonists. J Am Coll Cardiol 2009;53:1320–5. 5. Cheng TO, Kounis NG. Takotsubo cardiomyopathy, mental stress and the Kounis syndrome. Int J Cardiol 2012;161:65–7. 6. Kimmel SE, Sekeres M, Berlin JA, Ellison N. Mortality and adverse events after protamine administration in patients undergoing cardiopulmonary bypass. Anesth Analg 2002;94: 1402–8. table of contents. 7. Levy JH, Adkinson NF Jr. Anaphylaxis during cardiac surgery: implications for clinicians. Anesth Analg 2008;106:392–403. 8. Nybo M, Madsen JS. Serious anaphylactic reactions due to protamine sulfate: a systematic literature review. Basic Clin Pharmacol Toxicol 2008;103:192–6. 9. Cevik C, Nugent K, Shome GP, Kounis NG. Treatment of Kounis syndrome. Int J Cardiol 2010;143:223–6. 10. Aziz TA, Singh G, Popjes E, et al. Initial experience with CentriMag extracorporal membrane oxygenation for support of critically ill patients with refractory cardiogenic shock. J Heart Lung Transplant 2010;29:66–71.
Thoracoabdominal Aortic Aneurysm Repair in a Patient With a Left Ventricular Assist Device Kazuma Date, MD, Tatsuo Kaneko, MD, PhD, Masahiko Edure, MD, Yasushi Sato, MD, PhD, Yutaka Hasegawa, MD, PhD, Shuuichi Okada, MD, Shuuichi Okonogi, MD, Hitomi Takihara, MD, and Minoru Ono, MD, PhD Department of Cardiovascular Surgery, Gunma Prefectural Cardiovascular Center, Gunma, and Department of Cardiothoracic Surgery, The University of Tokyo, Tokyo, Japan
We report a case of thoracoabdominal aneurysm repair in a 44-year-old man with end-stage heart failure requiring an Accepted for publication Aug 7, 2013. Address correspondence to Dr Date, Department of Cardiothoracic Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.08.029
Ann Thorac Surg 2014;97:1778–81
CASE REPORT DATE ET AL ANEURYSM REPAIR WITH LV
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extracorporeal left ventricular assist device (LVAD). At the age of 31 years, the patient experienced type B acute aortic dissection, which gradually dilated to a maximum dimension of 66 mm at the diaphragm. The aneurysm prevented the patient from meeting heart transplantation criteria. For this reason and because of an increased risk of rupture, we undertook surgical repair of the aneurysm. This report constitutes the first such published case, and we describe the management of the LVAD in the perioperative period. (Ann Thorac Surg 2014;97:1778–81) Ó 2014 by The Society of Thoracic Surgeons
E
A 44-year old man was diagnosed with Stanford type B acute aortic dissection at the age of 31 years and was treated with medication. Subsequently, he had multiple hospital admissions for chronic heart failure and underwent implantation with a defibrillator at the age of 41 years for cardiac resynchronization therapy. His heart failure continued to progress gradually. By the age of 42 years, catecholamine withdrawal had become difficult because of clinical deterioration, and we decided to implant an extracorporeal LVAD (Toyobo LVAD, Nipro, Osaka, Japan). At the time of the procedure, his condition was profile 2 by Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) classification [1]. After LVAD implantation, aggressive cardiac rehabilitation could be performed, and his general condition improved. He experienced septic shock from methicillin-resistant Staphylococcus aureus (MRSA) 4 months after implantation but recovered with vancomycin administration. He continued rehabilitation while receiving vancomycin (1 g/d), but cardiac function did not improve further. He was considered for heart transplantation but was ineligible for the transplant registry because of the dissecting thoracoabdominal aortic aneurysm that had dilated to a maximum diameter of 66 mm at the level of the diaphragm (Fig 1). Considering the increasing likelihood of rupture, we elected surgical repair of the aneurysm. Surgical planning included consideration of anticoagulation therapy and infection control. Preoperative anticoagulation therapy with oral warfarin maintained the prothrombin time/international normalized ratio (PT/ INR) between 3.5 and 4.5. Antiplatelet therapy consisted of aspirin (100 mg/d). Aspirin treatment was suspended 7 days before the operation. Warfarin was suspended 2 days before the operation, and intravenous unfractionated heparin treatment was begun 4 days before the procedure. Vitamin K was also administered the day before and the day of the operation. Because of this therapy, the PT/INR was 1.30 immediately before induction of general anesthesia. Linezolid was used for antibiotic treatment during
Fig 1. Reconstructed 3-dimensional computed tomographic image showing preoperative aneurysm.
the perioperative period, with consideration for tissue migration and renal effects of vancomycin. After induction of general anesthesia, we first performed pump exchange for the Toyobo LVAD (Nipro, Osaka, Japan) because the new pump was considered superior for antithrombosis. After the exchange, the patient was placed in the right semilateral position and drapes were arranged to allow monitoring of the pump condition (Fig 2). We checked the blood pump of the LVAD during the procedure and regulated the driving frequency and percentage systole of the pump to maintain satisfactory “full fill” and “full empty” functions. We administered a normal amount of heparin and established extracorporeal circulation through drainage from the left femoral vein and injection into the left femoral artery. We first clamped the aorta just proximal to the celiac artery and just distal to the left renal artery and then cannulated the celiac, superior mesenteric, and left renal arteries. After reconstruction of the dissecting lumen, we selected a woven branched graft (J Graft SHIELD NEO, JUNKEN Medical/Japan Lifeline Group, Tokyo, Japan) and performed distal anastomosis just proximal to the left renal artery. We then reconstructed the celiac and superior mesenteric arteries. After shifting the proximal clamping site to the descending aorta, we
FEATURE ARTICLES
xtracorporeal left ventricular assist devices (LVADs) are most frequently used in Japan to support patients with end-stage heart failure. Clinical experience with LVAD-assisted cardiovascular operations has not been previously described to our knowledge. We report a surgical repair of a thoracoabdominal aneurysm using an LVAD.
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CASE REPORT DATE ET AL ANEURYSM REPAIR WITH LV
Fig 2. After the operation. Cranial side is to right and caudal side is to left. Pump is circled. Pump condition was checked during the operation.
FEATURE ARTICLES
reconstructed the intercostal arteries between the level of the 9th and 11th thoracic vertebrae and performed proximal anastomosis. After neutralization of heparin, weaning from extracorporeal circulation was smooth. Hemostasis was difficult but was finally achieved using a massive transfusion containing red cell concentrate, fresh-frozen plasma, and platelet concentrate. Two Blaketype drains were placed in the left thoracic cavity and retroperitoneal space. The operation time was 845 minutes, extracorporeal circulation time was 365 minutes, and aortic cross-cramp time was 315 minutes. Estimated blood loss was approximately 6,000 mL. The postoperative course was uneventful. The patient was extubated on postoperative day (POD) 1 and had no paraplegia. Anticoagulation therapy with heparin infusion was started on POD 2 and with oral warfarin and aspirin on POD 4. Two drains were removed sequentially by POD 6. Pump exchange was performed on POD 10 because of a floating thrombus in the pump. The patient was transferred from the intensive care unit to the general ward on POD 11 and resumed cardiac rehabilitation. No signs of infection were present.
Comment LVAD implantation is an accepted bridge-totransplantation strategy for patients with end-stage heart failure. In 2011, 2 implantable LVADs were approved in Japan. Pulsatile extracorporeal LVAD, primarily the Toyobo LVAD, had previously been used for patients with end-stage heart failure. The Toyobo LVAD was used as a long-term bridge to transplantation, for longer than 2 years in some cases, because fewer than 100 organ transplants from brain-dead donors were performed during the entire year before revision of the laws governing transplantation [2].
Ann Thorac Surg 2014;97:1778–81
The number of patients with continuous-flow LVADs requiring noncardiac surgery has increased [3]. However, to our knowledge, no studies have reported on cardiovascular surgical procedures with LVADs. Our patient had several preoperative problems, including chronic heart failure and the requirement for anticoagulation therapy. His history of septic shock also elevated the risk of vascular graft infection. Although his preoperative cardiac function had not improved, his exercise tolerance had improved in cardiopulmonary exercise test results with LVAD support, and he had been able to care for himself. He was therefore considered a good candidate for surgical intervention with an LVAD. Preoperative anticoagulation therapy was also a major concern. The Toyobo LVAD, a pneumatic pump, causes more thromboembolic events and requires stronger anticoagulation than required for an implantable continuous-flow pump. Control of PT/INR between 3 and 4 is recommended in Japan for patients with a Toyobo LVAD [4]. Stronger anticoagulation was indicated in our patient because of a history of pump thrombus. Minimizing the amount of bleeding may conflict with preventing thrombus formation in the pump. We continued intravenous unfractionated heparin, whereas oral warfarin and aspirin were suspended. The oral drugs were restarted carefully while monitoring tube drainage. Although heparin and protamine for neutralizing heparin were administered intraoperatively in the usual manner, hemostasis presented challenges. Hemorrhage was controlled with a massive transfusion, but pump replacement was required 10 days postoperatively. Our anticoagulation therapy in this procedure remains a matter for consideration and improvement. Finally, infection was an important issue. In the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) study, sepsis was the most common cause of death after LVAD operations [5]. This patient had MRSA, a known pathogen in LVAD-related infections. We changed his antibiotic from vancomycin to linezolid, a powerful antibiotic effective for MRSA and other gram-positive bacteria. Linezolid is useful for treating infections in unusual anatomic sites where therapeutic antibiotic levels cannot be achieved [6]. Adverse effects of linezolid include myelosuppression and pancytopenia. Our patient tolerated this drug well, but we plan to monitor his condition closely until heart transplantation. Strict planning and management contributed to our success, but the operation was nevertheless quite invasive for the patient. Therefore, technical advances, eg, branched stent-grafts, are important issues in Japan.
References 1. Stevenson LW, Pagani FD, Young JB, et al. INTERMACS profiles of advanced heart failure: the current picture. J Heart Lung Transplant 2009;28:535–41. 2. Sasaoka T, Kato TS, Komamura K, et al. Improved long-term performance of pulsatile extracorporeal left ventricular assist device. J Cardiol 2010;56:220–8.
Ann Thorac Surg 2014;97:1781–2
Uncertainty of Axillary Artery Perfusion During Surgery for Acute Aortic Dissection Kazuhito Imanaka, MD, PhD, Mitsuhiro Kawata, MD, PhD, Takahiro Matsuoka, MD, and Hideaki Yamabi, MD, PhD Department of Cardiovascular Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
We treated a patient with acute aortic dissection, which affected the innominate and carotid arteries. Although the true lumen was adequately wide and cerebral malperfusion deemed unlikely, extracorporeal circulation through the femoral artery caused right cerebral malperfusion, and addition of right axillary artery perfusion was ineffective. Several minutes after innominate artery snaring, cerebral blood flow was suddenly restored and the clinical outcome was favorable. Axillary artery perfusion is occasionally unreliable and inevitably demands careful cerebral flow monitoring. A dead-end false lumen in the innominate and carotid arteries requires special caution. A dual-artery perfusion strategy permits innominate artery occlusion as an emergency measure against unexpected malperfusion. (Ann Thorac Surg 2014;97:1781–2) Ó 2014 by The Society of Thoracic Surgeons
1781
S
ome surgeons highly recommend the axillary artery as an inflow site during surgery for acute type A aortic dissection (AAD). However, this strategy is occasionally unreliable. We describe a case in which addition of right axillary artery perfusion failed to resolve intraoperative right cerebral malperfusion. A 72-year-old woman with a small build had sudden severe back pain, and was diagnosed with AAD and cardiac tamponade. Although imaging studies disclosed a bilateral carotid artery dissection, the true lumen of the innominate and right common carotid arteries had adequate width, and no flow was detected in the false lumen (Fig 1). The patient underwent an emergency operation. Because the right carotid artery was unavailable owing to a central venous catheter previously placed in the right jugular vein, a 16F perfusion cannula was initially placed in the right femoral artery. Immediately after initiation of cardiopulmonary bypass (CPB), the regional oxygen saturation (rSO2) value of the right cerebral hemisphere disproportionally fell from 68% to 46% (Fig 2) and then rapidly recovered after cessation of CPB. Next, a 12F cannula was additionally placed in the right axillary artery, and we resumed CPB using both arteries for inflow. However, the right cerebral rSO2 value fell again and remained low even after the innominate artery was occluded using a silicone elastomer loop. Several minutes later, the rSO2 value of the right side rapidly elevated to a value higher than that of the left, although the exact mechanism of this recovery was unclear. The CPB was continued with the innominate artery kept snared, and the patient was cooled down to deep hypothermia. A large intimal tear was found in the ascending aorta. After a vascular prosthesis was anastomosed to the distal part of the ascending aorta, perfusion was resumed through the graft, and the rSO2 value remained stable thereafter. The patient regained consciousness 4 hours later, and the postoperative course was uneventful. In follow-up examinations, the false lumen of the innominate and right carotid arteries eventually shrunk.
Comment Accepted for publication Aug 19, 2013. Address correspondence to Dr Imanaka, Department of Cardiovascular Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamodatsujido, Kawagoe, Saitama 350-8550, Japan; e-mail: imanakaz@ saitama-med.ac.jp.
Cerebral malperfusion, even only during cooling or rewarming, may result in a dismal outcome. That appeared unlikely to occur in our patient before surgery as the true lumen of the innominate and carotid arteries was not at all stenotic, and there was scant blood flow in Fig 1. (A) Dissection affected the bilateral common carotid arteries. The false lumen of the right carotid artery was not opacified and the true lumen was not stenotic. (B) No significant flow was detected in the false lumen of the right carotid artery, whereas there was sufficient flow in the true lumen. A central venous catheter was placed in the right jugular vein (arrow).
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.08.046
FEATURE ARTICLES
3. Morgan JA, Paone G, Nemeh HW, et al. Non-cardiac surgery in patients on long-term left ventricular assist device support. J Heart Lung Transplant 2012;31:757–63. 4. Iwashima Y, Yanase M, Horio T, et al. Impact of pump replacement on outcome in advanced heart failure patients with left ventricular assist system. Artif Organs 2013;37: 606–14. 5. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 2001;345:1435–43. 6. Bassetti M, Di Biagio A, Del Bono V, Cenderello G, Bassetti D. Successful treatment of methicillin-resistant Staphylococcus aureus endocarditis with linezolid. Int J Antimicrob Agents 2004;24:83–4.
CASE REPORT IMANAKA ET AL UNCERTAINTY OF AXILLARY ARTERY PERFUSION
CASE REPORT DATE ET AL ANEURYSM REPAIR WITH LV
FEATURE ARTICLES
syndrome [1]. Lacking plausible alternative explanations, we contend that the most likely immediate cause of the postoperative circulatory collapse was an anaphylactic reaction to protamine and that the profound LV dysfunction resulted in part from the massive doses of catecholamines administered during resuscitation in the setting of immune-mediated coronary hypersensitivity (Kounis’ syndrome) [5]. In all likelihood, the patient survived the catastrophic hemodynamic collapse thanks to the prompt institution of ECMO. A protamine reaction is defined as an adverse event that occurs within 30 minutes of administration of protamine and in the absence of other plausible explanations; it is associated with profound hypotension, abrupt pulmonary hypertension, noncardiogenic pulmonary edema, or bronchospasm, or a combination [6]. The incidence of protamine-induced hypotension and anaphylaxis is 10.7% [7] and 0.19% [8], respectively. Risk factors include high dose/rapid administration of protamine, fish allergy, vasectomy, and protamine-associated drugs (insulin), none of which applied here [7]. Although the pathogenic mechanism of Takotsubo’s syndrome remains unclear, one theory implicates stressinduced catecholamine release, producing cardiac stunning [1]. In most cases, an emotional or physical stress just before the onset of symptoms can be identified, and the majority of patients are women, suggesting a link to endocrine factors [1]. We postulate that rather than endogenous catecholamines, escalating doses of catecholamines administered in the course of resuscitation for a severe protamine reaction in our patient contributed to the severe LV dysfunction. In a recent report of 9 patients with transient LV dysfunction after intravenous administration of b-adrenergic agonists, 6 patients experienced stress cardiomyopathy after total doses of epinephrine of 1 to 40 mg, and in 3 patients it was triggered by dobutamine infusion during stress echocardiography [4]. However, the sequence of events in our patient (severe protamine reaction prompting administration of high doses of catecholamines followed by severe LV dysfunction) strongly suggests that release of inflammatory mediators triggered by a fulminant immune response to protamine set the stage for coronary hypersensitivity to catecholamines, ultimately potentiating the cardiac insult. Severe allergic and anaphylactic reactions, presumably through mast cell degranulation and coronary vasospasm, can cause angina and myocardial infarction in the absence of underlying coronary artery disease, a clinical scenario that has been termed Kounis’ syndrome [5, 9]. Unlike a typical protamine reaction, in this setting LV dysfunction can be aggravated acutely by administration of epinephrine, the drug of choice for the treatment of anaphylaxis. Thus, once this complication is recognized, strict avoidance of b-adrenergic drugs is critical, and treatment with antihistamines, corticosteroids, and vasodilators (if the blood pressure permits) should begin [9]. ECMO has emerged as a potent therapeutic tool in patients with potentially fatal acute circulatory collapse and allows an excellent short-term outcome in many cases [10]. We believe our patient illustrates this claim. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2014;97:1778–81
In summary, we have reported a case of postoperative Takotsubo’s syndrome in a young woman undergoing mitral valve repair complicated by a severe protamine reaction prompting resuscitation with large doses of catecholamines. Although epinephrine is considered essential in the management of anaphylactic shock, this case highlights the need for high vigilance regarding potentially serious adverse effects of catecholamines administered in this setting. An excellent outcome was made possible by prompt institution of femoral vein–to–femoral artery ECMO.
References 1. Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539–48. 2. Kogan A, Ghosh P, Schwammenthal E, Raanani E. Takotsubo syndrome after cardiac surgery. Ann Thorac Surg 2008;85: 1439–41. 3. Gariboldi V, Jop B, Grisoli D, Jaussaud N, Kerbaul F, Collart F. Takotsubo syndrome after mitral valve replacement for acute endocarditis. Ann Thorac Surg 2011;91:e31–2. 4. Abraham J, Mudd JO, Kapur NK, Klein K, Champion HC, Wittstein IS. Stress cardiomyopathy after intravenous administration of catecholamines and beta-receptor agonists. J Am Coll Cardiol 2009;53:1320–5. 5. Cheng TO, Kounis NG. Takotsubo cardiomyopathy, mental stress and the Kounis syndrome. Int J Cardiol 2012;161:65–7. 6. Kimmel SE, Sekeres M, Berlin JA, Ellison N. Mortality and adverse events after protamine administration in patients undergoing cardiopulmonary bypass. Anesth Analg 2002;94: 1402–8. table of contents. 7. Levy JH, Adkinson NF Jr. Anaphylaxis during cardiac surgery: implications for clinicians. Anesth Analg 2008;106:392–403. 8. Nybo M, Madsen JS. Serious anaphylactic reactions due to protamine sulfate: a systematic literature review. Basic Clin Pharmacol Toxicol 2008;103:192–6. 9. Cevik C, Nugent K, Shome GP, Kounis NG. Treatment of Kounis syndrome. Int J Cardiol 2010;143:223–6. 10. Aziz TA, Singh G, Popjes E, et al. Initial experience with CentriMag extracorporal membrane oxygenation for support of critically ill patients with refractory cardiogenic shock. J Heart Lung Transplant 2010;29:66–71.
Thoracoabdominal Aortic Aneurysm Repair in a Patient With a Left Ventricular Assist Device Kazuma Date, MD, Tatsuo Kaneko, MD, PhD, Masahiko Edure, MD, Yasushi Sato, MD, PhD, Yutaka Hasegawa, MD, PhD, Shuuichi Okada, MD, Shuuichi Okonogi, MD, Hitomi Takihara, MD, and Minoru Ono, MD, PhD Department of Cardiovascular Surgery, Gunma Prefectural Cardiovascular Center, Gunma, and Department of Cardiothoracic Surgery, The University of Tokyo, Tokyo, Japan
We report a case of thoracoabdominal aneurysm repair in a 44-year-old man with end-stage heart failure requiring an Accepted for publication Aug 7, 2013. Address correspondence to Dr Date, Department of Cardiothoracic Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.08.029
Ann Thorac Surg 2014;97:1778–81
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extracorporeal left ventricular assist device (LVAD). At the age of 31 years, the patient experienced type B acute aortic dissection, which gradually dilated to a maximum dimension of 66 mm at the diaphragm. The aneurysm prevented the patient from meeting heart transplantation criteria. For this reason and because of an increased risk of rupture, we undertook surgical repair of the aneurysm. This report constitutes the first such published case, and we describe the management of the LVAD in the perioperative period. (Ann Thorac Surg 2014;97:1778–81) Ó 2014 by The Society of Thoracic Surgeons
E
A 44-year old man was diagnosed with Stanford type B acute aortic dissection at the age of 31 years and was treated with medication. Subsequently, he had multiple hospital admissions for chronic heart failure and underwent implantation with a defibrillator at the age of 41 years for cardiac resynchronization therapy. His heart failure continued to progress gradually. By the age of 42 years, catecholamine withdrawal had become difficult because of clinical deterioration, and we decided to implant an extracorporeal LVAD (Toyobo LVAD, Nipro, Osaka, Japan). At the time of the procedure, his condition was profile 2 by Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) classification [1]. After LVAD implantation, aggressive cardiac rehabilitation could be performed, and his general condition improved. He experienced septic shock from methicillin-resistant Staphylococcus aureus (MRSA) 4 months after implantation but recovered with vancomycin administration. He continued rehabilitation while receiving vancomycin (1 g/d), but cardiac function did not improve further. He was considered for heart transplantation but was ineligible for the transplant registry because of the dissecting thoracoabdominal aortic aneurysm that had dilated to a maximum diameter of 66 mm at the level of the diaphragm (Fig 1). Considering the increasing likelihood of rupture, we elected surgical repair of the aneurysm. Surgical planning included consideration of anticoagulation therapy and infection control. Preoperative anticoagulation therapy with oral warfarin maintained the prothrombin time/international normalized ratio (PT/ INR) between 3.5 and 4.5. Antiplatelet therapy consisted of aspirin (100 mg/d). Aspirin treatment was suspended 7 days before the operation. Warfarin was suspended 2 days before the operation, and intravenous unfractionated heparin treatment was begun 4 days before the procedure. Vitamin K was also administered the day before and the day of the operation. Because of this therapy, the PT/INR was 1.30 immediately before induction of general anesthesia. Linezolid was used for antibiotic treatment during
Fig 1. Reconstructed 3-dimensional computed tomographic image showing preoperative aneurysm.
the perioperative period, with consideration for tissue migration and renal effects of vancomycin. After induction of general anesthesia, we first performed pump exchange for the Toyobo LVAD (Nipro, Osaka, Japan) because the new pump was considered superior for antithrombosis. After the exchange, the patient was placed in the right semilateral position and drapes were arranged to allow monitoring of the pump condition (Fig 2). We checked the blood pump of the LVAD during the procedure and regulated the driving frequency and percentage systole of the pump to maintain satisfactory “full fill” and “full empty” functions. We administered a normal amount of heparin and established extracorporeal circulation through drainage from the left femoral vein and injection into the left femoral artery. We first clamped the aorta just proximal to the celiac artery and just distal to the left renal artery and then cannulated the celiac, superior mesenteric, and left renal arteries. After reconstruction of the dissecting lumen, we selected a woven branched graft (J Graft SHIELD NEO, JUNKEN Medical/Japan Lifeline Group, Tokyo, Japan) and performed distal anastomosis just proximal to the left renal artery. We then reconstructed the celiac and superior mesenteric arteries. After shifting the proximal clamping site to the descending aorta, we
FEATURE ARTICLES
xtracorporeal left ventricular assist devices (LVADs) are most frequently used in Japan to support patients with end-stage heart failure. Clinical experience with LVAD-assisted cardiovascular operations has not been previously described to our knowledge. We report a surgical repair of a thoracoabdominal aneurysm using an LVAD.
1780
CASE REPORT DATE ET AL ANEURYSM REPAIR WITH LV
Fig 2. After the operation. Cranial side is to right and caudal side is to left. Pump is circled. Pump condition was checked during the operation.
FEATURE ARTICLES
reconstructed the intercostal arteries between the level of the 9th and 11th thoracic vertebrae and performed proximal anastomosis. After neutralization of heparin, weaning from extracorporeal circulation was smooth. Hemostasis was difficult but was finally achieved using a massive transfusion containing red cell concentrate, fresh-frozen plasma, and platelet concentrate. Two Blaketype drains were placed in the left thoracic cavity and retroperitoneal space. The operation time was 845 minutes, extracorporeal circulation time was 365 minutes, and aortic cross-cramp time was 315 minutes. Estimated blood loss was approximately 6,000 mL. The postoperative course was uneventful. The patient was extubated on postoperative day (POD) 1 and had no paraplegia. Anticoagulation therapy with heparin infusion was started on POD 2 and with oral warfarin and aspirin on POD 4. Two drains were removed sequentially by POD 6. Pump exchange was performed on POD 10 because of a floating thrombus in the pump. The patient was transferred from the intensive care unit to the general ward on POD 11 and resumed cardiac rehabilitation. No signs of infection were present.
Comment LVAD implantation is an accepted bridge-totransplantation strategy for patients with end-stage heart failure. In 2011, 2 implantable LVADs were approved in Japan. Pulsatile extracorporeal LVAD, primarily the Toyobo LVAD, had previously been used for patients with end-stage heart failure. The Toyobo LVAD was used as a long-term bridge to transplantation, for longer than 2 years in some cases, because fewer than 100 organ transplants from brain-dead donors were performed during the entire year before revision of the laws governing transplantation [2].
Ann Thorac Surg 2014;97:1778–81
The number of patients with continuous-flow LVADs requiring noncardiac surgery has increased [3]. However, to our knowledge, no studies have reported on cardiovascular surgical procedures with LVADs. Our patient had several preoperative problems, including chronic heart failure and the requirement for anticoagulation therapy. His history of septic shock also elevated the risk of vascular graft infection. Although his preoperative cardiac function had not improved, his exercise tolerance had improved in cardiopulmonary exercise test results with LVAD support, and he had been able to care for himself. He was therefore considered a good candidate for surgical intervention with an LVAD. Preoperative anticoagulation therapy was also a major concern. The Toyobo LVAD, a pneumatic pump, causes more thromboembolic events and requires stronger anticoagulation than required for an implantable continuous-flow pump. Control of PT/INR between 3 and 4 is recommended in Japan for patients with a Toyobo LVAD [4]. Stronger anticoagulation was indicated in our patient because of a history of pump thrombus. Minimizing the amount of bleeding may conflict with preventing thrombus formation in the pump. We continued intravenous unfractionated heparin, whereas oral warfarin and aspirin were suspended. The oral drugs were restarted carefully while monitoring tube drainage. Although heparin and protamine for neutralizing heparin were administered intraoperatively in the usual manner, hemostasis presented challenges. Hemorrhage was controlled with a massive transfusion, but pump replacement was required 10 days postoperatively. Our anticoagulation therapy in this procedure remains a matter for consideration and improvement. Finally, infection was an important issue. In the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) study, sepsis was the most common cause of death after LVAD operations [5]. This patient had MRSA, a known pathogen in LVAD-related infections. We changed his antibiotic from vancomycin to linezolid, a powerful antibiotic effective for MRSA and other gram-positive bacteria. Linezolid is useful for treating infections in unusual anatomic sites where therapeutic antibiotic levels cannot be achieved [6]. Adverse effects of linezolid include myelosuppression and pancytopenia. Our patient tolerated this drug well, but we plan to monitor his condition closely until heart transplantation. Strict planning and management contributed to our success, but the operation was nevertheless quite invasive for the patient. Therefore, technical advances, eg, branched stent-grafts, are important issues in Japan.
References 1. Stevenson LW, Pagani FD, Young JB, et al. INTERMACS profiles of advanced heart failure: the current picture. J Heart Lung Transplant 2009;28:535–41. 2. Sasaoka T, Kato TS, Komamura K, et al. Improved long-term performance of pulsatile extracorporeal left ventricular assist device. J Cardiol 2010;56:220–8.
Ann Thorac Surg 2014;97:1781–2
Uncertainty of Axillary Artery Perfusion During Surgery for Acute Aortic Dissection Kazuhito Imanaka, MD, PhD, Mitsuhiro Kawata, MD, PhD, Takahiro Matsuoka, MD, and Hideaki Yamabi, MD, PhD Department of Cardiovascular Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
We treated a patient with acute aortic dissection, which affected the innominate and carotid arteries. Although the true lumen was adequately wide and cerebral malperfusion deemed unlikely, extracorporeal circulation through the femoral artery caused right cerebral malperfusion, and addition of right axillary artery perfusion was ineffective. Several minutes after innominate artery snaring, cerebral blood flow was suddenly restored and the clinical outcome was favorable. Axillary artery perfusion is occasionally unreliable and inevitably demands careful cerebral flow monitoring. A dead-end false lumen in the innominate and carotid arteries requires special caution. A dual-artery perfusion strategy permits innominate artery occlusion as an emergency measure against unexpected malperfusion. (Ann Thorac Surg 2014;97:1781–2) Ó 2014 by The Society of Thoracic Surgeons
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ome surgeons highly recommend the axillary artery as an inflow site during surgery for acute type A aortic dissection (AAD). However, this strategy is occasionally unreliable. We describe a case in which addition of right axillary artery perfusion failed to resolve intraoperative right cerebral malperfusion. A 72-year-old woman with a small build had sudden severe back pain, and was diagnosed with AAD and cardiac tamponade. Although imaging studies disclosed a bilateral carotid artery dissection, the true lumen of the innominate and right common carotid arteries had adequate width, and no flow was detected in the false lumen (Fig 1). The patient underwent an emergency operation. Because the right carotid artery was unavailable owing to a central venous catheter previously placed in the right jugular vein, a 16F perfusion cannula was initially placed in the right femoral artery. Immediately after initiation of cardiopulmonary bypass (CPB), the regional oxygen saturation (rSO2) value of the right cerebral hemisphere disproportionally fell from 68% to 46% (Fig 2) and then rapidly recovered after cessation of CPB. Next, a 12F cannula was additionally placed in the right axillary artery, and we resumed CPB using both arteries for inflow. However, the right cerebral rSO2 value fell again and remained low even after the innominate artery was occluded using a silicone elastomer loop. Several minutes later, the rSO2 value of the right side rapidly elevated to a value higher than that of the left, although the exact mechanism of this recovery was unclear. The CPB was continued with the innominate artery kept snared, and the patient was cooled down to deep hypothermia. A large intimal tear was found in the ascending aorta. After a vascular prosthesis was anastomosed to the distal part of the ascending aorta, perfusion was resumed through the graft, and the rSO2 value remained stable thereafter. The patient regained consciousness 4 hours later, and the postoperative course was uneventful. In follow-up examinations, the false lumen of the innominate and right carotid arteries eventually shrunk.
Comment Accepted for publication Aug 19, 2013. Address correspondence to Dr Imanaka, Department of Cardiovascular Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamodatsujido, Kawagoe, Saitama 350-8550, Japan; e-mail: imanakaz@ saitama-med.ac.jp.
Cerebral malperfusion, even only during cooling or rewarming, may result in a dismal outcome. That appeared unlikely to occur in our patient before surgery as the true lumen of the innominate and carotid arteries was not at all stenotic, and there was scant blood flow in Fig 1. (A) Dissection affected the bilateral common carotid arteries. The false lumen of the right carotid artery was not opacified and the true lumen was not stenotic. (B) No significant flow was detected in the false lumen of the right carotid artery, whereas there was sufficient flow in the true lumen. A central venous catheter was placed in the right jugular vein (arrow).
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.08.046
FEATURE ARTICLES
3. Morgan JA, Paone G, Nemeh HW, et al. Non-cardiac surgery in patients on long-term left ventricular assist device support. J Heart Lung Transplant 2012;31:757–63. 4. Iwashima Y, Yanase M, Horio T, et al. Impact of pump replacement on outcome in advanced heart failure patients with left ventricular assist system. Artif Organs 2013;37: 606–14. 5. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 2001;345:1435–43. 6. Bassetti M, Di Biagio A, Del Bono V, Cenderello G, Bassetti D. Successful treatment of methicillin-resistant Staphylococcus aureus endocarditis with linezolid. Int J Antimicrob Agents 2004;24:83–4.
CASE REPORT IMANAKA ET AL UNCERTAINTY OF AXILLARY ARTERY PERFUSION
