From the Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany.
Submitted for consideration June 2010; accepted for publication in revised form October 2010.
Reprint Requests: Alexander Stepanenko, MD, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, Berlin 13353, Germany. Email: email@example.com.
Right ventricular (RV) support in the case of RV failure after left ventricular assist device (LVAD) implantation is a well-established surgical therapeutic option. However, there is a serious limitation of RV support after the insertion of a LVAD through lateral thoracotomy in patients who have undergone previous multiple cardiac operations. We describe a modified surgical approach for implantation of right ventricular assist devices (RVADs) via left lateral thoracotomy, with venous cannulation via a femoral vein and transpericardial outflow cannulation of the main pulmonary artery by Seldinger technique under echocardiographic monitoring. This technique was successfully used in a case with subsequent weaning from the RVAD after 10 days of support.
Right ventricular failure (RVF) is a major cause of morbidity and early postoperative mortality in patients suffering from end-stage heart failure who have undergone placement of a left ventricular assist device (LVAD).1 Poor LVAD output with prolonged shock in the case of right ventricular (RV) failure may lead to deterioration in the function of predamaged end organs. Right ventricular assist device (RVAD) insertion in this case is a valid therapy option. However, concomitant implementation of an RVAD after LVAD insertion via left lateral thoracotomy in patients who have undergone previous multiple cardiac operations remains difficult.
A 61-year-old male multimorbid patient with ischemic cardiomyopathy (triple-vessel disease, s.p. coronary artery bypass grafting [CABG] in April 2009 [all three bypasses to left artheria descending (LAD), ramus interventricular posterior (RIVP), and 1 diagonal artery (D1) are patent]; s.p. mitral valve and tricuspid valve repair [rings] in August 2009 for severe incompetence; cardiac resynchronization therapy with automatic implantable cardioverter defibrillator [AICD] cardiac resinchronization therapy [CRT] implantation in August 2009, diabetes mellitus, and chronic kidney disease) underwent HeartWare LVAD (Framingham, MA) implantation via left lateral thoracotomy for terminal heart failure at our institution.
For left ventricular assist device (LVAD) implantation, a double-lumen endotracheal tube is inserted to allow deflation of the left lung. With the patient having been placed in the right lateral 45° decubitus position, the groin vessels are exposed, and a left lateral thoracotomy is performed in the fifth intercostal space. In systemic heparinization a femoral-femoral cardiopulmonary bypass with normothermia is initiated, and LVAD implantation is performed with cannulation of the left ventricular (LV) apex in the fibrillating heart and with connection of the outflow graft to the descending aorta, as described by our working group previously.2,3 Transesophageal echocardiography (TEE) is performed to check that LVAD apical cannula position is optimal, without signs of malposition or intracardiac obstruction.
RV failure occurred in the present case on the first postoperative day. The patient was transferred to the operating room (OR) for RVAD placement. The left groin was reopened, and after heparin bolusing, two purse-string 5-0 polypropylene sutures were placed on the femoral vein. The venous cannula of the RVAD (23-F femoral Medtronic Biomedicus DLP cannula, Medtronic, Minneapolis, MN) was advanced through the inferior vena cava into the cavum of the right atrium using the Seldinger technique. The location and hemostasis were secured by purse-string sutures and cutaneous fixation. The groin wound was provisionally closed.
After reopening of the chest and visual localization of the main pulmonary artery, two additional purse-string sutures supported with pledgets (5-0 polypropylene) were placed at the pericardium to protect the left lateral aspect of the artery. The main pulmonary artery was punctured with a needle under TEE monitoring. Pressure measurement and blood gas analysis confirmed correct position of the needle in the lumen of the main pulmonary artery. The outflow cannula of the RVAD (22-F DLP Elongated One-Piece Arterial Cannula [EOPA], Medtronic, Minneapolis, MN) was advanced transpericardially into the main pulmonary artery (4 cm from tip of cannula to pericardial tissue with location of the cannula tip close to the bifurcation in TEE) using the Seldinger technique. Hemostasis was achieved and the cannula position secured by purse-string sutures with additional fixation to the pericardial tissue (approximately 5 cm from cannulation point) and cutaneous fixation in the ventral edge of the thoracotomy wound. Daily x-ray examinations showed no sign of dislodgement of either RVAD cannula (Figure 1).
After careful deairing of the cannulas and connection to the RVAD pump (Levitronix, Waltham, MA), RV support was initiated. Cannula sizes were selected to maintain RVAD flow of 5 L/min, which adequately supported the LVAD flow of above 6 L/min. Multilayer chest closure was performed after meticulous hemostasis.
After 5 days of RV unloading, a weaning protocol with stepwise RVAD flow reduction was applied together with a subsequent increase in heparin dosage to allow progressively lower levels of RVAD support. Inotropes and inhaled nitric oxide may be of value in similar cases. After 10 days of support, the RVAD was explanted in the OR.
The venous cannula is surgically explanted, and, after hemostasis is ensured, definitive multilayer closure of the groin wound is performed. Prevention of acute embolization from the femoral vein distally to the RVAD cannula may be of value. The arterial cannula of the RVAD is explanted through chest reopening. After release of ligatures, with gentle traction, the cannula is removed from the pulmonary artery, and purse-string sutures are placed. No signs of dissection of pulmonary artery or wall hematoma formation were found in TEE in our patient.
Several reports have shown the feasibility of minimally invasive RVAD insertion using different approaches. Cohn et al.4 described RVAD insertion through vessel grafts with bedside removal. Strauch et al.5 suggested a modified technique for RVAD insertion via sternotomy. Minami et al.6 described cannulation of the outflow graft through the right pulmonary artery between the ascending aorta and the superior vena cava using Seldinger technique, to avoid excessive adhesion dissection in cases of reoperation. However, there is little reported information about RVAD insertion via a left lateral thoracotomy or alternative means of RV support in such scenarios as in our case, where the patient had undergone two cardiac operations within the previous 5 months. Peripheral venoarterial extracorporeal membrane oxygenation (ECMO) for maintaining systemic circulation may be of value. However, the ECMO flow in this approach is limited and may carry an additional thromboembolic and bleeding risk for the patient. Son et al.7 presented an animal and cadaver feasibility study to show possible means of ventricular assist device (VAD) implantation via right thoracotomy. Our approach is limited if there are severe adhesions after left lung decortication or previous thoracic surgery or lack of TEE to localize the main pulmonary artery transpericardially. Using self-expanding smart venous cannulas may minimize the risk of venous thrombosis and maintain sufficient perfusion of the leg if RV recovery is expected to be prolonged.
In conclusion, insertion of a RVAD after LVAD implantation via left lateral thoracotomy using venous cannulation via the femoral vein and outflow cannulation of the main pulmonary artery traspericardially via the left chest under transesophageal monitoring provides excellent hemodynamic support for the treatment of postoperative RV failure. This approach should be used only when the risks and complications of a repeat median sternotomy are prohibitive and an alternative approach does not increase the surgical risk.
The authors thank Anne Gale, Medical Editor, Deutsches Herzzentrum, Berlin, Germany, for her editorial assistance and the MCS team of DHZB: Dr. Ewald Hennig, Friedrich Kaufmann, and Ursula Seiler for their technical support.
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