Cannulation strategy for centrifugal-flow ventricular assist device implantation late after arterial switch operation

Cannulation strategy for centrifugal-flow ventricular assist device implantation late after... Abstract The field of paediatric ventricular assist device (VAD) support is growing rapidly. Among paediatric patients, those with complex congenital heart disease represent a challenging population for VAD support. This report describes a patient with a remote history of an arterial switch operation for d-transposition of the great arteries who developed ischaemic cardiomyopathy necessitating centrifugal-flow VAD support as a bridge to cardiac transplantation. Because of the unique anatomy and the complicated vascular situation, implantation of the centrifugal-flow VAD and subsequent explantation for cardiac transplantation required modifications to the standard surgical approach. The details of surgical pitfalls encountered are described. Ventricular assist device, Arterial switch operation, Cannulation, Transplantation INTRODUCTION Currently, the paediatric experience with centrifugal-flow ventricular assist devices (CF-VADs) implantation is mostly limited to patients with normally structured hearts such as dilated cardiomyopathy [1]. There is, however, an increasing number of patients with complex congenital heart disease (CHD) undergoing CF-VAD support [2]. When applying CF-VADs in this complex population, the implant should be tailored to account for the individual’s unique anatomy. Herein, we present a case of CF-VAD implantation and subsequent cardiac transplantation in a patient with a history of an arterial switch operation. CASE A 16-year-old male patient (42 kg, body surface area 1.3 m2) with a history of d-transposition was transferred to our centre for decompensated heart failure. The patient underwent an arterial switch operation as a neonate. The arterial switch operation was complicated by coronary occlusion, which required coronary artery bypass grafting, and transient extracorporeal membrane oxygenation support. He subsequently underwent device closure of a residual atrial septal defect. He developed ischaemic cardiomyopathy with severe mitral regurgitation, requiring 2 attempts of mitral valve repair. He also underwent placement of a transvenous automatic implantable cardioverter–defibrillator. All of these interventions were performed at an outside institution. On admission, the chronicity of his illness was evident, with severe malnutrition and cachexia. Echocardiography demonstrated severe mitral regurgitation and severely depressed biventricular function. Despite inotropic support and non-invasive positive pressure ventilation, his cardiac output remained marginal. Worsening heart failure with recurrent ventricular tachyarrhythmias prompted urgent CF-VAD placement. Intraoperatively, the innominate vein was found to be immobile due to the cardioverter–defibrillator leads, limiting the exposure of the proximal arch and neck vessels. Because of the previous Lecompte manoeuvre (i.e. anterior relocation of the pulmonary artery during an arterial switch operation), the entire ascending aorta was obscured. Attempts to mobilize the pulmonary artery and proximal aortic arch were hindered due to haemodynamic instability. Given the orientation of the great arteries, it was apparent that the CF-VAD outflow graft would need to be anastomosed to the base of the innominate artery. Therefore, the right subclavian artery cannulation was not deemed to be an ideal option, as the perfusion could be compromised when the innominate artery was clamped during graft anastomosis. The left subclavian artery was also not accessible due to the presence of the defibrillator generator. The right femoral artery was completely occluded. The left femoral artery was the only remaining option. After dissecting out the left femoral artery, it was found to be small (∼5.5 mm in diameter). A 6-mm Gelsoft graft (Terumo Cardiovascular Corp., Ann Arbor, MI, USA) was anastomosed in an end-to-side fashion. Cardiopulmonary bypass was initiated after cannulating the femoral chimney graft and the right atrium. Unfortunately, the arterial limb of the bypass circuit demonstrated an unacceptably high line pressure, due to the small size of the femoral artery. To maintain the line pressure within an acceptable range (<250 mmHg), the bypass flow was kept ‘partial’. This allowed sufficient haemodynamic stability to complete mobilization of the innominate artery. Test occlusion of the innominate artery showed minimal changes in brain near-infrared spectroscopy. The CF-VAD outflow graft was cut approximately into half, and the free piece was anastomosed to the proximal innominate artery (Fig. 1). The graft was cannulated with an 18-Fr arterial cannula for bypass perfusion, and the arterial perfusion was transitioned from the femoral to the innominate artery graft, which enabled ‘full-flow’ bypass. The HVAD® (Medtronic Inc., Minneapolis, MN, USA) was then inserted in the left ventricle in our standard fashion [3]. At this point, the bypass perfusion was reduced to partial flow, and the arterial perfusion was transitioned back from the innominate graft to the femoral artery graft. This allowed safe anastomosis of the CF-VAD outflow graft to the innominate artery graft. After appropriate deairing, cardiopulmonary bypass was weaned off as the HVAD support was increased. Cardiopulmonary bypass time was 170 min, and the lowest temperature during the surgery was 32°C. Given the marginal right ventricular performance, the chest was kept open for 36 h. Postoperative recovery was uneventful, with discharge on postoperative Day 30. The patient experienced favourable rehabilitation as an outpatient and was listed for cardiac transplantation (Fig. 2). Five months after the implantation, a suitable organ became available for cardiac transplant. Since the aorta was not accessible for cannulation during transplantation, the HVAD outflow graft was cannulated directly and used for bypass perfusion. The previous Lecompte manoeuvre was reversed to allow anastomosis of the pulmonary artery in the anatomical position. The patient did well and was discharged home on postoperative Day 17. Figure 1 View largeDownload slide Because of the anterior location of the pulmonary artery, the outflow graft of the ventricular assist device was sewn to the base of the innominate artery. inn.V: innominate vein; LCCA: left common carotid artery; RCCA: right common carotid artery; RSCA: right subclavian artery; SVC: superior venacava. Figure 1 View largeDownload slide Because of the anterior location of the pulmonary artery, the outflow graft of the ventricular assist device was sewn to the base of the innominate artery. inn.V: innominate vein; LCCA: left common carotid artery; RCCA: right common carotid artery; RSCA: right subclavian artery; SVC: superior venacava. Figure 2 View largeDownload slide (A) Pre- and (B) post-X-rays have shown a significant reduction in cardiac silhouette. The inflow cannula of the HVAD is pointing towards the mitral valve, which is demarcated with the annuloplasty ring. Figure 2 View largeDownload slide (A) Pre- and (B) post-X-rays have shown a significant reduction in cardiac silhouette. The inflow cannula of the HVAD is pointing towards the mitral valve, which is demarcated with the annuloplasty ring. COMMENT The surgical pitfalls in this case primarily originated from the complex nature of previous interventions, which made the anatomy challenging for placement of a CF-VAD. Nonetheless, this case demonstrates that a successful outcome can be achieved with appropriate surgical planning. Although CHD currently accounts for only 10% of children undergoing CF-VAD support according to the PediMACS report [1], this number will certainly increase in the near future. In our centre, nearly a third (14 of 38) of HVAD implantations are in patients with complex CHD. We hope that this report will stimulate further discussion on VAD support in the CHD patient population. Conflict of interest: none declared. REFERENCES 1 Rossano JW, Lorts A, VanderPluym CJ, Jeewa A, Guleserian KJ, Bleiweis MS et al.   Outcomes of pediatric patients supported with continuous-flow ventricular assist devices: a report from the Pediatric Interagency Registry for Mechanical Circulatory Support (PediMACS). J Heart Lung Transplant  2016; 35: 585– 90. Google Scholar CrossRef Search ADS PubMed  2 Adachi I, Burki S, Fraser CDJr. Current status of pediatric ventricular assist device support. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu  2017; 20: 2– 8. Google Scholar CrossRef Search ADS PubMed  3 Adachi I, Guzmán-Pruneda FA, Jeewa A, Fraser CDJr, Dean McKenzie E. A modified implantation technique of the HeartWare ventricular assist device for pediatric patients. J Heart Lung Transplant  2015; 34: 134– 6. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

Cannulation strategy for centrifugal-flow ventricular assist device implantation late after arterial switch operation

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Oxford University Press
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© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1569-9293
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Abstract

Abstract The field of paediatric ventricular assist device (VAD) support is growing rapidly. Among paediatric patients, those with complex congenital heart disease represent a challenging population for VAD support. This report describes a patient with a remote history of an arterial switch operation for d-transposition of the great arteries who developed ischaemic cardiomyopathy necessitating centrifugal-flow VAD support as a bridge to cardiac transplantation. Because of the unique anatomy and the complicated vascular situation, implantation of the centrifugal-flow VAD and subsequent explantation for cardiac transplantation required modifications to the standard surgical approach. The details of surgical pitfalls encountered are described. Ventricular assist device, Arterial switch operation, Cannulation, Transplantation INTRODUCTION Currently, the paediatric experience with centrifugal-flow ventricular assist devices (CF-VADs) implantation is mostly limited to patients with normally structured hearts such as dilated cardiomyopathy [1]. There is, however, an increasing number of patients with complex congenital heart disease (CHD) undergoing CF-VAD support [2]. When applying CF-VADs in this complex population, the implant should be tailored to account for the individual’s unique anatomy. Herein, we present a case of CF-VAD implantation and subsequent cardiac transplantation in a patient with a history of an arterial switch operation. CASE A 16-year-old male patient (42 kg, body surface area 1.3 m2) with a history of d-transposition was transferred to our centre for decompensated heart failure. The patient underwent an arterial switch operation as a neonate. The arterial switch operation was complicated by coronary occlusion, which required coronary artery bypass grafting, and transient extracorporeal membrane oxygenation support. He subsequently underwent device closure of a residual atrial septal defect. He developed ischaemic cardiomyopathy with severe mitral regurgitation, requiring 2 attempts of mitral valve repair. He also underwent placement of a transvenous automatic implantable cardioverter–defibrillator. All of these interventions were performed at an outside institution. On admission, the chronicity of his illness was evident, with severe malnutrition and cachexia. Echocardiography demonstrated severe mitral regurgitation and severely depressed biventricular function. Despite inotropic support and non-invasive positive pressure ventilation, his cardiac output remained marginal. Worsening heart failure with recurrent ventricular tachyarrhythmias prompted urgent CF-VAD placement. Intraoperatively, the innominate vein was found to be immobile due to the cardioverter–defibrillator leads, limiting the exposure of the proximal arch and neck vessels. Because of the previous Lecompte manoeuvre (i.e. anterior relocation of the pulmonary artery during an arterial switch operation), the entire ascending aorta was obscured. Attempts to mobilize the pulmonary artery and proximal aortic arch were hindered due to haemodynamic instability. Given the orientation of the great arteries, it was apparent that the CF-VAD outflow graft would need to be anastomosed to the base of the innominate artery. Therefore, the right subclavian artery cannulation was not deemed to be an ideal option, as the perfusion could be compromised when the innominate artery was clamped during graft anastomosis. The left subclavian artery was also not accessible due to the presence of the defibrillator generator. The right femoral artery was completely occluded. The left femoral artery was the only remaining option. After dissecting out the left femoral artery, it was found to be small (∼5.5 mm in diameter). A 6-mm Gelsoft graft (Terumo Cardiovascular Corp., Ann Arbor, MI, USA) was anastomosed in an end-to-side fashion. Cardiopulmonary bypass was initiated after cannulating the femoral chimney graft and the right atrium. Unfortunately, the arterial limb of the bypass circuit demonstrated an unacceptably high line pressure, due to the small size of the femoral artery. To maintain the line pressure within an acceptable range (<250 mmHg), the bypass flow was kept ‘partial’. This allowed sufficient haemodynamic stability to complete mobilization of the innominate artery. Test occlusion of the innominate artery showed minimal changes in brain near-infrared spectroscopy. The CF-VAD outflow graft was cut approximately into half, and the free piece was anastomosed to the proximal innominate artery (Fig. 1). The graft was cannulated with an 18-Fr arterial cannula for bypass perfusion, and the arterial perfusion was transitioned from the femoral to the innominate artery graft, which enabled ‘full-flow’ bypass. The HVAD® (Medtronic Inc., Minneapolis, MN, USA) was then inserted in the left ventricle in our standard fashion [3]. At this point, the bypass perfusion was reduced to partial flow, and the arterial perfusion was transitioned back from the innominate graft to the femoral artery graft. This allowed safe anastomosis of the CF-VAD outflow graft to the innominate artery graft. After appropriate deairing, cardiopulmonary bypass was weaned off as the HVAD support was increased. Cardiopulmonary bypass time was 170 min, and the lowest temperature during the surgery was 32°C. Given the marginal right ventricular performance, the chest was kept open for 36 h. Postoperative recovery was uneventful, with discharge on postoperative Day 30. The patient experienced favourable rehabilitation as an outpatient and was listed for cardiac transplantation (Fig. 2). Five months after the implantation, a suitable organ became available for cardiac transplant. Since the aorta was not accessible for cannulation during transplantation, the HVAD outflow graft was cannulated directly and used for bypass perfusion. The previous Lecompte manoeuvre was reversed to allow anastomosis of the pulmonary artery in the anatomical position. The patient did well and was discharged home on postoperative Day 17. Figure 1 View largeDownload slide Because of the anterior location of the pulmonary artery, the outflow graft of the ventricular assist device was sewn to the base of the innominate artery. inn.V: innominate vein; LCCA: left common carotid artery; RCCA: right common carotid artery; RSCA: right subclavian artery; SVC: superior venacava. Figure 1 View largeDownload slide Because of the anterior location of the pulmonary artery, the outflow graft of the ventricular assist device was sewn to the base of the innominate artery. inn.V: innominate vein; LCCA: left common carotid artery; RCCA: right common carotid artery; RSCA: right subclavian artery; SVC: superior venacava. Figure 2 View largeDownload slide (A) Pre- and (B) post-X-rays have shown a significant reduction in cardiac silhouette. The inflow cannula of the HVAD is pointing towards the mitral valve, which is demarcated with the annuloplasty ring. Figure 2 View largeDownload slide (A) Pre- and (B) post-X-rays have shown a significant reduction in cardiac silhouette. The inflow cannula of the HVAD is pointing towards the mitral valve, which is demarcated with the annuloplasty ring. COMMENT The surgical pitfalls in this case primarily originated from the complex nature of previous interventions, which made the anatomy challenging for placement of a CF-VAD. Nonetheless, this case demonstrates that a successful outcome can be achieved with appropriate surgical planning. Although CHD currently accounts for only 10% of children undergoing CF-VAD support according to the PediMACS report [1], this number will certainly increase in the near future. In our centre, nearly a third (14 of 38) of HVAD implantations are in patients with complex CHD. We hope that this report will stimulate further discussion on VAD support in the CHD patient population. Conflict of interest: none declared. REFERENCES 1 Rossano JW, Lorts A, VanderPluym CJ, Jeewa A, Guleserian KJ, Bleiweis MS et al.   Outcomes of pediatric patients supported with continuous-flow ventricular assist devices: a report from the Pediatric Interagency Registry for Mechanical Circulatory Support (PediMACS). J Heart Lung Transplant  2016; 35: 585– 90. Google Scholar CrossRef Search ADS PubMed  2 Adachi I, Burki S, Fraser CDJr. Current status of pediatric ventricular assist device support. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu  2017; 20: 2– 8. Google Scholar CrossRef Search ADS PubMed  3 Adachi I, Guzmán-Pruneda FA, Jeewa A, Fraser CDJr, Dean McKenzie E. A modified implantation technique of the HeartWare ventricular assist device for pediatric patients. J Heart Lung Transplant  2015; 34: 134– 6. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Journal

Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Mar 1, 2018

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