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A Journal on Cardiac, Vascular and Thoracic Surgery

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The Journal of Cardiovascular Surgery 1999 October;40(5):627-31

language: English

Methods of ­acute post­car­di­otomy ­left ven­tric­ular assis­tance

Reardon M. J., Conklin L. Dl., Letsou G. V., Safi H. J., Espada R., Baldwin J. C.

From the Depart­ment of Sur­gery Baylor Col­lege of Med­i­cine Meth­o­dist Hos­pital, ­Houston, ­Texas, USA


Objec­tive. ­Despite ­many tech­no­log­ical ­advances in car­di­o­vas­cular sur­gery, ­some ­patients ­still expe­ri­ence post­car­di­otomy ­left ven­tric­ular (LV) ­failure ­that is refrac­tory to ­both ­inotropic sup­port and ­intra-­aortic bal­loon ­pump (­IABP) place­ment. The pri­mary ­author (MJR) ­recently ­changed ­from ­inflow can­nu­la­tion at the ­right ­superior pul­mo­nary ­vein/­left ­atrial junc­tion to ­inflow can­nu­la­tion at the ­dome of the ­left ­atrium. The pur­pose of ­this ­study was to com­pare ­data col­lected ­during place­ment of a ­left ven­tric­ular ­assist ­device (­LVAD) at the junc­tion of the ­right ­superior pul­mo­nary ­vein ­with posi­tioning the ­device in the ­dome of the ­left ­atrium. Experi­mental ­design, set­ting, and par­tic­i­pants: the med­ical ­records of all ­patients under­going car­diac sur­gery by one ­author (MJR) ­between 1994 and 1997 ­were ret­ro­spec­tively ­reviewed, and 4 ­patients ­requiring ­LVAD place­ment for ­short ­term post­car­di­otomy sup­port ­were iden­ti­fied. ­Each ­patient’s ­chart was ­reviewed for dura­tion of ­LVAD sup­port, ­average ­LVAD ­blood ­flows, pul­mo­nary cap­il­lary ­wedge pres­sures (­PCWP), pre­op­er­a­tive char­ac­ter­is­tics, post­op­er­a­tive com­pli­ca­tions, and ­final out­come for the ­patients.
­Results. ­Accessing the ­left ­atrium ­through the ­dome ­resulted in excel­lent ­blood ­flow ­through the ­LVAD and ­allowed for ­good LV decom­pres­sion. Hemo­stasis ­remained the ­most ­common com­pli­ca­tion regard­less of the tech­nique ­employed; how­ever, the ­enhanced vis­ibility pro­vided by ­accessing the ­left ­atrium via the ­dome ­made ­repairs ­less tech­ni­cally dif­fi­cult. ­Three ­patients (75%) ­were ­able to be ­weaned ­from the ­LVAD and ­were dis­charged ­from the hos­pital to ­home. Two of ­these ­patients ­were can­nu­lated via the ­left ­atrial ­dome ­making ­removal of the ­LVAD ­easier, ­thus ­exposing the ­patients to ­less addi­tional oper­a­tive ­time. One ­patient ­could not be ­weaned ­from ­LVAD sup­port sec­on­dary to devel­op­ment of ­right ven­tric­ular ­failure ­requiring ­RVAD inser­tion and sub­se­quent devel­op­ment of mul­tiple ­organ ­failure syn­drome.
Con­clu­sions. ­Patients ­requiring LV assis­tance fol­lowing car­di­o­pul­mo­nary ­bypass sur­gery tra­di­tion­ally ­have ­high ­levels of mor­bidity and mor­tality. In ­spite of the com­pli­ca­tions asso­ciated ­with the place­ment of an ­assist ­device, we ­remain encour­aged by the excel­lent LV decom­pres­sion and ­systemic ­flows we ­achieved fol­lowing implan­ta­tion of the ­LVAD ­through the ­dome of the ­left ­atrium. The ­superior ­ease of implan­ta­tion and decan­nu­la­tion pro­vided ­better oper­a­tive ­care and post­op­er­a­tive man­age­ment for our ­patients.

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