Asian Cardiovasc Thorac Ann 2007;15:243-245
© 2007 Asia Publishing EXchange Ltd
Successful Mechanical Circulatory Support as a Bridge to Transplantation
Sak Lee, MD,
Young-Hwan Park, MD,
Sang-Hyun Lim, MD,
Young-Tae Kwak, MD,
Hoon Kim, MD1,
Byung-Chul Chang, MD
Division of Thoracic and Cardiovascular Surgery, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul
1 Han-maum Clinic, Pusan, Korea
For reprint information contact: Byung-Chul Chang, MD Tel: 82 2 2228 8483 Fax: 82 2 313 2992 Email: bcchang{at}yumc.yonsei.ac.kr, Division of Thoracic and Cardiovascular Surgery, Cardiovascular Center, Yonsei University College of Medicine, (120-752) 134 Shinchon-dong, Seodaemoon-gu, Seoul, Korea.
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ABSTRACT
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With the progression of congestive heart failure, therapeutic options become fewer, and cardiac transplantation is the final option. The use of a left ventricular assist device improves the survival rate and quality of life in patients on the waiting list for transplantation. A 64-year-old man was successfully maintained on mechanical circulatory support with a left ventricular assist device for 502 days, as a bridge to transplantation.
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INTRODUCTION
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The incidence of congestive heart failure is gradually increasing due to aging of the population and improved medical management that allows the disease to develop. As congestive heart failure progresses to end-stage heart failure, therapeutic options become fewer, and cardiac transplantation is eventually the only remaining option. Unfortunately, transplantation is the most limited option due to the shortage of donor hearts, and many candidates die on the waiting list.1 Since the introduction of cyclosporine, mechanical circulatory support has been used extensively as a bridge to transplantation in high-risk patients.2,3
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CASE REPORT
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A 64-year old man with dilated cardiomyopathy on regular follow-up was admitted to our hospital for cardiac transplantation. An echocardiogram in 1998 had revealed a dilated heart with an ejection fraction of 15%. Thereafter, he was admitted several times for conservative management of heart failure. Two years later, he underwent mitral valve annuloplasty (29 mm Duran ring), tricuspid annuloplasty, a modified Dor procedure, and left ventricular assist device (LVAD) implantation (HeartMate 1000, Thermocardiosystems Inc., Woburn, MA, USA) due to chronic heart failure resulting from anteroseptal and anterior wall akinesia coupled with thinning, grade 2/4 mitral valve regurgitation, and grade 2/4 tricuspid valve regurgitation, with an ejection fraction of 18%. After implantation of the LVAD, the patient was registered on the Korean Network for Organ Sharing (KONOS) that was founded in February 2002 to pursue efficient organ donation, procurement, and transplantation, based on the organ transplantation law in Korea.
As younger candidates and those who registered on KONOS earlier had priority, the patient had a long wait for cardiac transplantation. After 502 days, a donor heart became available, and he underwent orthotopic heart transplantation and LVAD explantation (Figure 1
). On verifying the quality of the donor heart, a classic median sternotomy was performed. Arterial and venous cannulas were inserted through the femoral artery and vein. Severe mediastinal adhesion was carefully dissected under cardiopulmonary bypass, and another venous cannula was inserted through the right atrium. Left ventricular assist device pumping was discontinued, and the outflow unit was resected. After cross clamping the aorta, the inflow unit was resected, and the air-drive line of the LVAD was also resected at the inlet portion of the pocket. The LVAD was removed. The skin around the drive-line of the LVAD had become infected and adhered robustly, making it impossible to remove. Instead, it was resected at the inlet portion, and a pursestring suture was applied to seal the connection with the outside of the pocket. The prepared donor heart was trimmed, and a vent was inserted through the left atrial appendage. Iced saline was infused through the vent. The left and right atria and the aorta were sutured continuously. The aortic cross clamp was removed after injection of 500 mg of Solu-Medrol, and the coronary arteries were perfused. Initiating rewarming, the residual right atrium and pulmonary artery were sutured, and the patient was successfully weaned off cardiopulmonary bypass. He was transferred to the intensive care unit with stable vital signs. He was extubated the following day and transferred to a general ward on the 5th postoperative day. A postoperative echocardiogram revealed adequate ventricular function, and an endomyocardial biopsy showed no graft rejection. At the 3-year follow-up, the patient was doing well in New York Heart Association functional class II.
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Figure 1. Chest radiograph (A) at 7 weeks and (B) 502 days after LVAD implantation. The inflow cannula was inserted into the apex of the left ventricle, and the outflow cannula was anastomosed to the ascending aorta. The pumping chamber was placed within the abdominal wall.
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DISCUSSION
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As the result of experience with mechanical assist devices since 1964, many patients have recovered to New York Heart Association class I cardiac status before they could undergo cardiac transplantation.4,5 Furthermore, recently developed devices enhance the patient’s physical capacity, allowing recovery of ventricular and end-organ function, and also improving the quality of life while awaiting a donor heart.4 Patient selection for LVAD implantation is a critical issue that profoundly influences outcomes. The two most important factors are the appropriateness of device implantation, based on need, and the risk of LVAD implantation to the patient.6 Patients who die between device insertion and transplantation primarily perish due to multi-organ failure, renal failure, right ventricular failure, and infection.7 Therefore, those over 50-years old who require preoperative cardiopulmonary resuscitation or long-term ventilatory support, or who exhibit renal dysfunction, should be considered high-risk candidates for LVAD implantation.6 The 1-year survival rate in patients with a LVAD as a bridge to transplantation is 89%, which is similar or even higher than that of patients who receive a heart without circulatory support.4
In the near future, more advanced systems with internal batteries will last longer. It is also expected that smaller consoles will be developed, and many patients waiting for donor hearts can anticipate a longer life expectancy and better quality of life with the help of these systems. Many cases of successful LVAD treatment as a bridge to transplantation have been reported worldwide. In this case, the patient had suffered heart failure for many years, with expected survival of less than 1 year, and no donor heart available for transplantation. Thus, we implanted the LVAD and successfully prolonged survival with mechanical circulatory support for 502 days as a bridge to transplantation.
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REFERENCES
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- Salzberg S, Lachat M, Zund G, Oechslin E, Schmid ER, DeBakey M, et al. Left ventricular assist device as bridge to heart transplantation-lessons learned with the MicroMed DeBakey axial blood flow pump. Eur J Cardiothorac Surg 2003;24:113–8.[Abstract/Free Full Text]
- Frazier OH, Rose EA, McCarthy P, Burton NA, Tector A, Levin H, et al. Improved mortality and rehabilitation of transplant candidates treated with a long-term implantable left ventricular assist system. Ann Surg 1995;222:327–38.[Medline]
- Poirier VL. Worldwide experience with the TCI HeartMate system: issues and future perspective. Thorac Cardiovasc Surg 1999;47 Suppl 2:316–20.[Medline]
- Frazier OH. Long-term mechanical circulatory support. Edmunds, LH Jr, editor. Cardiac surgery in the adult. 1st ed. Pennsylvania: McGraw-Hill. 1997;1477–90.
- Vitali E, Lanfranconi M, Bruschi G, Ribera E, Garatti A, Colombo T, et al. Mechanical circulatory support in severe heart failure: single-center experience. Transplant Proc 2004;36:620–2.[Medline]
- Aaronson KD, Patel H, Pagani FD. Patient selection for left ventricular assist device therapy. Ann Thorac Surg 2003;75(6 Suppl):S29–35.[Abstract/Free Full Text]
- Miller LW. Patient selection for the use of ventricular assist devices as a bridge to transplantation. Ann Thorac Surg 2003;75(6 Suppl):S66–71.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
