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Opening the “Dor,” Not Always an Inferior Approach

Wagle, Sugat; Lakhani, Baqir A.; CHAUDHRY, SUNIT-PREET; Ravichandran, Ashwin K.; SALERNO, CHRISTOPHER T.

doi: 10.1097/MAT.0000000000000919
Case Reports
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The Dor procedure was historically used to restore the geometry of the heart in a patient with a left ventricular (LV) aneurysm via reduction and reshaping of the LV with an aneurysmectomy. Unfortunately, morbidity and mortality remain high with this procedure, with many patients little to no recovery of their ejection fraction while developing severe diastolic failure, often requiring further support; however, the natural history of these patients remains largely unknown. Heart transplant has long been considered the most durable of treatment for patients with end-stage heart failure (HF), but because of the scarcity of donor hearts, the implantation of left ventricular assist devices (LVAD) for mechanical circulatory support has also proven to be an essential tool in the treatment of the advanced heart failure patient. While various techniques for LVAD implantation have been well outlined, there is very limited literature on placement of a VAD in patients with a history of LV aneurysmectomy or Dor procedures, particularly with regard to the challenging aspects of apical cannulation in those with prior apical ventriculotomy and patch placement. In this series, we describe three patients with a history of LV aneurysmectomy procedures who underwent Heartware ventricular assist device (HVAD) implantations for end-stage HF.

From the Departments of Cardiology and Cardiovascular Surgery, St. Vincent Hospital Indianapolis, Indianapolis, Indiana.

Submitted for consideration July 2018; accepted for publication in revised form October 2018.

Disclosure: The authors have no conflicts of interest to report.

Correspondence: Sugat Wagle, St. Vincent Hospital Indianapolis. Email: sugat.wagle@ascension.org.

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Case 1

Sixty year old man with a history of a large anterior myocardial infarction (MI) in 1991 with history of ischemic cardiomyopathy underwent left ventricular (LV) apical aneurysmectomy in 1995. He continued to have symptomatic HF despite optimal guideline-directed medical therapy, and eventually progressed on to worsening LV dysfunction with an ejection fraction of 20% and LV end-diastolic diameter of 6.6 cm. Because of his New York Heart Association (NYHA) class IV symptomology and an ongoing smoking history, the decision was made to move forward with mechanical circulatory support with LV assist device (LVAD). Because of his history of aneurysmectomy and dense, intrapericardial adhesions, placement into the true apex was not possible. Heartware ventricular assist device (HVAD) was chosen because of its ability to allow for placement on the diaphragmatic surface of the ventricle. Figure 1 demonstrates a postoperative bedside chest x-ray after placement of the HVAD. He has had a successful postoperative course with a 30 day length of stay in the hospital, no readmissions and currently NYHA class II symptomatology nearly 2 years out.

Figure 1

Figure 1

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Case 2

Seventy-four year old man suffered anteroseptal MI in 1987 because a subtotal occluded LAD requiring emergency angioplasty, as well as multiple other left anterior descending artery (LAD) interventions including repeat angioplasty x2 and bare-metal stenting between 1991 and 2002. Developed a large anteroapical scar and underwent LV aneurysmectomy with Dor procedure and single-vessel saphenous vein graft to mid LAD in 2001, and subsequent implantable cardioverter defibrillator placement because of severe LV dysfunction and refractory ventricular tachycardia. In 2015, his progressed from stable NYHA class II symptomatology for more than 25 years to eventual NYHA class IV, inotrope dependent symptoms by December 2015. Because of his continued severe LV dysfunction, ejection fraction of 10% with LV end-diastolic diameter of 6.7 cm, severe mitral and tricuspid regurgitation, the decision was made to proceed with destination therapy (DT) LVAD. The HVAD was chosen because of its versatility in the setting of previous LV aneurysmectomy with the Dor procedure. Figure 2 demonstrates a bedside postprocedure chest x-ray. His health, currently after receiving greater than 2 years of support, has been complicated by pulmonary issues from long-term amiodarone therapy.

Figure 2

Figure 2

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Case 3

Fifty-four year old man with a history of LV apical thrombus related to ischemic cardiomyopathy with severe LV systolic dysfunction underwent LV resection via Dor procedure in March 2004. Because of significant biventricular failure with NYHA class IV symptoms, mechanical circulatory support was used as a bridge to transplant in November 2017. With his anatomical considerations in mind, an HVAD was placed via the diaphragmatic approach. Figure 3 demonstrates a postoperative chest x-ray. Immediate postoperative course was complicated by an ileus, which resolved with supportive measures. Unfortunately, he developed refractory ventricular arrhythmias requiring the placement of a percutaneous right ventricular device before eventual orthotopic heart transplantation in March 2018.

Figure 3

Figure 3

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Discussion

This case series identifies three patients undergoing successful HVAD implantation despite challenging anatomy because of their remote histories of LV aneurysmectomy via the Dor procedure. All three patients had NYHA class IV symptoms in the setting of severe LV dysfunction refractory to medical management requiring multiple admissions.

The surgical approach in our series differs from the one described by Palmen et al.,5 where the HVAD was implanted directly through the aneurysm repair. Our technique includes choosing the cannulation site at the mid portion of the diaphragmatic surface of the LV in a site free from calcification, avoiding the papillary muscles and mitral valve leaflets using preoperative assessment with transesophageal echocardiogram and computed tomography guidance. The LV is completely mobilized to aid in exposure, with the cuff then subsequently sewn in place using a standard coring technique. No pump pocket is created. After the sewing cuff is in place, careful inspection of the LV cavity through the cuff is crucial to avoid any potential obstructive anatomy. The HVAD is then inserted and secured, with the outflow graft being measured and anastomosed to the aorta in standard fashion. The final pump position is with the body of the HVAD parallel to the diaphragm and the inflow portion directed cephalad.

The HVAD was successful in serving as a bridge to transplant in our final patient and is providing successful destination therapy for our two initial patients. This case series demonstrates successful HVAD implantation in patients with history of prior LV apical aneurysmectomy with the above outlined surgical technique.

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Acknowledgment

No databases were accessed and no patient identifiers were used.

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References

1. Athanasuleas C, Buckberg G, Stanley A, et al. Surgical ventricular restoration in the treatment of congestive heart failure due to post-infarction ventricular dilation. J ACC Col Cardiol 2004.44: 1439–1445.
    2. Hunt SA, Ea R. The REMATCH trial: Long-term use of a left ventricular assist device for end-stage heart failure. J Cardiac Failure 2002.8: 59–60.
      3. Osaki S, Edwards NM, Kohmoto T. Strategies for left ventricular assist device insertion after the Dor procedure. J Heart Lung Transplant 2009.28: 520–522.
      4. Radovancevic B, Frazier OH, Duncan JM. Implantation technique for the HeartMate left ventricular assist device. J Card Surg 1992.7: 203–207.
      5. Palmen M, Verwey HF, Haeck ML, Holman ER, Schalij MJ, Klautz RJ. Implantation of a left ventricular assist device in patients with a complex apical anatomy. Ann Thorac Surg 2012.94: 2122–2125.
      Keywords:

      LVAD; Dor; end-stage; heart failure; aneurysmectomy

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