Implantable LVAD insertion in patients with previous heart surgery

Presented at Congestive Heart Failure: The Issues in the Treatment of the Advanced Disease; Miltan, Italy, September 28 to October 1, 1997
https://doi.org/10.1016/S1053-2498(99)00103-5Get rights and content

Abstract

Implantable LVAD insertion and support poses technical obstacles in patients with previous heart operations. In this study of 135 LVAD patients (64 pneumatic HeartMate; 39 vented-electric HeartMate; 32 Novacor devices), 72 (53%) had previous heart surgery. For patients with previous coronary artery bypass, the grafts were managed by replacement or preservation. For patients with ventricular aneursym (or aneursmysectomy), or partical left ventriculectomy, apical cannulation had to be modified to maintain precise unobstructed orientation of the inflow cannula towards the mitral valve. Mechanical mitral and aortic prostheses were rereplaced with tissue valves. Implantable cardioverter defibrillators were removed, or the LVAD pump was placed intraperitoneal and the generator was left in the abdominal wall pocket. There were no significant differences in reoperations for bleeding (22% primary vs 23% reoperations), perioperative RVAD support (12% primary vs 7% reoperation) or survival to transplant (82% primary vs 72% reoperations). In conclusion adjustment of standard LVAD implant technique can successfully manage most problems posed by patients with previous heart surgery.

Section snippets

Patients and methods

From December 1991 until September 1997, 135 implantable LVADs were placed including: 64 pneumatic HeartMate devices (ThermoCardiosystems, Inc.; Woburn, MA), 39 vented-electric HeartMate LVADs, and 32 Novacor pumps (Baxter-Novacor; Oakland, CA) since December 1996. The mean age of the patients was 52 years (range 14 years to 71 years). The mean body surface area was 1.93 m2 (range 1.4 to 2.34) and 86% of the patients were male. The etiology of the cardiomyopathy was ischemic in 69% of patients.

Standard LVAD implant techniques and modifications

All operations were performed through a sternotomy incision with extension below the xiphoid. Earlier experience extended the incision to the umbilicus, but now the incision is brought only two inches below the xiphoid. This decreases the risk of abdominal wound dehiscence. Also, in our early experience a large pocket was made for LVAD pump placement behind the left rectus muscle.5 A limited dissection was made behind the right rectus muscle. Now the pocket is placed behind the posterior rectus

Results/discussion

The physiology of LVAD support is different from that encountered in most cardiac surgery. A thorough understanding of the effects of this physiology are important to successful LVAD implantation, especially in reoperations. Care must be taken to minimize bleeding which can contribute to right heart dysfunction. Aprotinin and fresh frozen plasma are routinely used during implants.7, 9 The surgeon must direct the apical inflow cannula towards the mitral valve and away from the septum or anterior

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