Download Prolonged Use of Levitronix Left Ventricular Assist Device as a

Acta Cardiol Sin 2015;31:249-252
Case Report
doi: 10.6515/ACS20140421A
Prolonged Use of Levitronix Left Ventricular
Assist Device as a Bridge to Heart Transplantation
Shih-Ying Sung,1 Po-Shun Hsu,1 Jia-Lin Chen,2 Chien-Sung Tsai,1 Yi-Ting Tsai,1 Chih-Yuan Lin,1 Chung-Yi Lee,1
Hong-Yan Ke1 and Yi-Chang Lin1
A 61-year-old male presented to our emergency room with chest tightness, dyspnea, and cold sweat. He underwent a
12-lead EKG which showed ST-elevation from leads V1-V4 and T wave inversion in leads II, III, and aVF. His
troponin-I level was elevated to 70.3 ng/ml. He went into cardiogenic shock when he was in the catheter room.
After advanced cardiac life support was administered for 30 min, veno-arterial extracorporeal membrane oxygenation
(VA-ECMO) cannulation was set up using 21-french arterial and 21-french venous cannula through the right femoral
artery and right femoral vein by the puncture method for hemodynamic support. Subsequently, a coronary artery
bypass graft (CABG) for acute myocardial infarction was performed. However, the patient was unable to be weaned
from the VA-ECMO. Four days later, a CentriMag (Levitronix LLC, Waltham, MA, USA) left ventricular assist device
(LVAD) was applied to avoid ECMO-related complications such as severe hemolysis, ischemic, deteriorated liver
and renal function. The patient subsequently underwent a successful orthotopic heart transplant after 87 days on
the CentriMag LVAD. The patient was extubated on the next postoperative day and was discharged 2 weeks later.
Key Words:
Acute myocardial infarction · Extracorporeal membrane oxygenation · Heart transplantation ·
Ventricular assist device
INTRODUCTION
siderably longer period than ECMO with reduced morbidity.3 We suggest timely implantation of VAD in critical
patients when the ECMO-related complications occur.
Over the past two decades, we have primarily used
intra-aortic balloon pump (IABP) and extracorporeal
membrane oxygenation (ECMO)1,2 as a bridge to cardiac
transplantation in patients with end-stage heart failure.
However, because of the shortage of cardiac transplants
in Taiwan, most patients died of ECMO-related morbidity while still on the waiting list. 2 The CentriMag
(Levitronix LLC, Waltham, MA, USA) ventricular assist
device (VAD) could provide cardiac support for a con-
CASE REPORT
A 61-year-old man presented to our emergency
room complaining of chest tightness, dyspnea and cold
sweats since the early morning. His symptoms did not
subside after resting. The patient did not have a prior
history of smoking but did have a medical history of hypertension that had been controlled with oral medication for 15 years. His 12-lead EKG showed ST-elevation
from leads V1-V4 and T wave inversion in leads II, III,
and aVF. His troponon-I level was elevated to 70.3 ng/
ml. The patient was diagnosed with a myocardial infarction. An emergent coronary artery angiogram showed
severe chronic occlusion of triple vessels and percutaneous coronary intervention was planned for revas-
Received: November 19, 2013 Accepted: April 21, 2014
1
Division of Cardiovascular Surgery, Department of Surgery;
2
Department of Anesthesia, Tri-Service General Hospital, National
Defense Medical Center, Taipei, Taiwan.
Address correspondence and reprint requests to: Dr. Chien-Sung
Tsai, Division of Cardiovascular Surgery, Department of Surgery,
Tri-Service General Hospital, No. 325, Cheng-Kung Rd., Sec. 2, Taipei
114, Taiwan. Tel: 886-2-8792-7212; Fax: 886-2-8792-7376; E-mail:
[email protected]
249
Acta Cardiol Sin 2015;31:249-252
Shih-Ying Sung et al.
ventricle (ejection fraction: 15-20%), despite optimal
inotrope administration (Table 1) and VA-ECMO support. The plain chest film showed engorgement of the
pulmonary trunk with mild pulmonary edema. The actual bleeding amount from mediastinum drainage was
470 ml on the post-operative day (POD) 1 and 210 ml on
the POD 2. At the same time, the patient was listed for
urgent cardiac transplantation. On the POD 4, severe
hemolysis and ECMO-related ischemic limb were noted.
In addition, deteriorated liver function and renal function with progressive oliguria was noted (Table 1). We
subsequently exchanged the VA-ECMO to left ventricular assist device (LVAD) for long-term cardiac support. A
continuous-flow CentriMag (Levitronix LLC, Waltham,
MA) LVAD was implanted. By way of re-sternotomy and
under guidance of trans-esophageal echocardiography
(TEE), the venous drainage tube was inserted from the
superior pulmonary vein into the left ventricular apex
while the arterial tube was inserted into the ascending
aorta (Figure 1). Purse strings with non-absorbable suture were secured with tourniquets, and spigots were
tied around the cannulae. The systolic function of the
right heart was stable on low-dose inotropic support.
Over the next two days, the patient remained hemodynamically stable on the LVAD and was weaned from
cularization over the culprit point of proximal left anterior descending artery. The IABP was inserted through
the left femoral artery before the cardiac catheterization examination. During the examination, the patient’s hemodynamic status suddenly collapsed due to
ventricular fibrillation. After providing a half-hour of advanced cardiac life support, Veno-arterial (VA)-ECMO
cannulation was set up with 21-french arterial and
21-french venous cannula via the right femoral artery
and the right femoral vein by puncture method for
hemodynamic support. The blood flow of VA-ECMO was
3200 ml/h and pump speed 2900 rpm. The vital signs of
the patient during surgery were heart rate: 62 beats/
minute and blood pressure 84/53 mmHg with inotropic
agent (dopamine: 12.8 mcg/kg/ min and epinephrine:
0.3 mcg/min). Emergent coronary bypass graft with total revascularization was performed under cardiopulmonary bypass with cardiac arrest. The four vein grafts
were harvested from the bilateral great saphenous veins
for bypass from the aorta to the left anterior descending
artery, left circumflex artery, first diagonal branch and
posterior descending artery. However, the extracorporeal circulation could not be weaned without VAECMO. In the intensive care unit, the daily cardiac echocardiographs showed very poor contractility of the left
Table 1.
Cardiac enzyme
CK
CKMB
Troponin-I
Renal function
BUN
Creatine
Urine amount (ml)
Liver function
GOT
GPT
Total Bilirubin
Inotropic agent
Dopamine (mcg/kg/min)
Dobutamine (mcg/kg/min)
Epinephrine (mcg/min)
Norepinephrine (mcg/min)
POD1
POD3
POD4 (LVAD)
POD5
POD10
POD20
POD40
POD91 (HT)
584
1513
> 100
127
40
1.2
98
18
0.44
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
15
1.2
3244
24
1.5
2160
36
2.0
980
30
1.2
2480
30
0.9
4390
13
0.6
5150
7
0.6
3190
8
0.8
3660
213
176
1.1
198
172
1.9
218
188
1.2
128
77
0.9
48
49
0.9
none
none
none
none
none
none
18
11
0.9
8.33
8.33
0.1
8
10.94
8.75
0
13.3
8.31
6.56
0
8
5.58
5.58
0
0
5.95
3.21
0
0
2.16
1.73
0
0
0
0
0
0
0
0
0
0
BUN, blood urea nitrogen; CK, creatine kinase; CKMB, creatine kinase MB coenzyme; GOT, glutamic-oxaloacetic transaminase; GPT,
glutamic-pyruvic transaminase; HT, Heart Transplant; LVAD, left ventricular assist device; POD, post-operative day.
Acta Cardiol Sin 2015;31:249-252
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LVAD as a Bridge to Heart Transplantation
ventricular assist devices are available, which provide
much longer durability and fewer complications than
ECMO. 3-5 In our institution we have extensive experience with the use of ECMO for cardiac failure after cardiac surgery, but complications always arose as time
passed, in particular significant morbidities related to
long-term intensive care stay, sedation, and ventilation
while on ECMO. Based on our data, the weaning rate of
VA-ECMO for heart failure is approximately 40%.2
Right now, VAD is categorized into two major types,
including pulsatile-flow and continuous-flow. We chose
CentriMag (Levitronix LLC, Waltham, MA) VAD for several reasons. First, recent studies have shown better
outcomes in continuous-flow than in pulsatile-flow. The
complications of continuous-flow type are also lower,
particularly with regard to the incidence of bleeding and
thromboembolism.6,7 Second, we still expect the recovery of the stunned myocardium after an acute myocardial infarction. Therefore, we abandoned the most advanced VAD, such as HeartMate II or BerlinHeart, in
which cannulation on the ventricular apex for drainage
is necessary. We opted to use CentriMag because we
could cannulate the drainage tube on the right superior
pulmonary vein (Figure 2) instead of ventricular apex,
where infarcted myocardium might be involved. To get
optimal drainage blood flow, we used peri-operative TEE
to guide the tube from the right superior pulmonary
vein into the left ventricle. The Snell-tie method was
used to tightly fix both the drainage and perfusion
tubes. (Figure 2) Closure of the insertion wound would
Figure 1. Peri-operative trans-esophageal echocardiography. The
venous drainage tube (white arrow) was inserted from the right
superior pulmonary vein, through the left atrium (LA), mitral valve and
into the left ventricle (LV).
long-term sedation and ventilation. Three days later, the
patient was transferred to the ordinary ward. Systemic
heparinization was provided through a peripheral line to
keep active clotting time between 140-160 seconds
since the LVAD was inserted. We then bridged systemic
heparin and oral warfarin for three days. After that, we
prescribed only warfarin and checked the patient’s PT/
APTT every two days. No device-related complications
were noted. In the ward, the patient was able to perform daily activities and tolerated quick steps. The
hemolysis subsided and his renal function improved. We
tried to wean him off the CentriMag LVAD, but failed
due to the unsustainable systolic function. The patient
(blood type A Rh +) underwent a successful orthotopic
cardiac transplantation (donor blood type O Rh +) after
87 days on the CentriMag LVAD. The four vein grafts
were patent when we performed the heart transplantation. He was extubated on the next postoperative day
and discharged home 2 weeks later after a total hospital
stay of 105 days. During his out-patient follow-up, no
cardiac rejection or device-related complications were
noted.
DISCUSSION
Before the popular application of VAD, ECMO played
an important role in the hemodynamic support for
end-stage heart failure.1,2 At present, various kinds of
Figure 2. Placement of the venous (black arrow) and arterial (white
arrow) tubes. Snell tie was used to tightly fix the tubes and to simplify
the removal.
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Acta Cardiol Sin 2015;31:249-252
Shih-Ying Sung et al.
REFERENCES
be very simple, quick and convenient once the VAD was
planned to be removed, whether the stunned myocardium recovered or heart transplantation was arranged. Finally, various kinds of VADs are available in
Taiwan but not recompensed in our National Health Insurance. In Taiwan, the CentriMag costs 12 thousand US
dollars, while the HeartMate II or BerlinHeart costs
more than 170 thousand US dollars. The patient’s family
was able to only afford the CentriMag. So we opted to
use the CentriMag instead of HeartMate II or BerlinHeart also because of economic considerations.
In conclusion, ECMO provided excellent short-term
cardiac mechanical support. However, for necessary extended periods of cardiac support, changing over to a
more long-term device is suggested to avoid ECMO-related morbidity.
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predictors of early mortality and outcome from 51 adult patients. Eur J Cardio-Thorac Surg 2010;37:328-33.
3. John R, Long JW, Massey HT, et al. Outcomes of a multicenter trial
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932-9.
4. Goldstein DJ, Oz MC, Rose EA. Implantable left ventricular assist
devices. N Engl J Med 1998;339:1522-33.
5. Arabia FA, Tsau PH, Smith RG, et al. Pediatric bridge to heart
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Thoratec ventricular assist devices. J Heart Lung Transplant
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6. Slaughter MS, Rogers JG, Milano CA, et al. Advanced heart failure
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7. Fang JC. Rise of the machines-left ventricular assist devices as
permanent therapy for advanced heart failure. N Engl J Med
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CONFLICTS OF INTEREST AND SOURCE OF FUNDING
None.
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