CASE ANECDOTES, COMMENTS AND OPINIONS Importance of pulmonary valve disease during implantation of a biventricular assist device Diana Reser, MD, Stephan Jacobs, MD, and Markus J. Wilhelm, MD, From the Clinic for Cardiovascular Surgery, University Hospital, Zurich, Switzerland.
The 2013 ISHLT guidelines for mechanical circulatory support recommend surgical intervention on the aortic valve during left ventricular assist device (LVAD) implantation in patients with more than mild aortic regurgitation.1 However, they do not refer to pulmonary regurgitation in patients who need right ventricular support. Herein we present the first reported case of simultaneous biventricular assist device implantation and pulmonary valve replacement for moderate pulmonary regurgitation. A 47-year-old patient was hospitalized with decompensated biventricular heart failure due to dilated cardiomyopathy. He had a history of pulmonary commissurotomy and infundibular resection at the age of 16 years for congenital infundibular and valvular stenosis of a bicuspid pulmonary valve. Despite treatment with levosimendan, the patient deteriorated further and emergent implantation of a peripheral venoarterial extracorporeal membrane oxygenation (ECMO) was required. After recovery of end-organ function on ECMO, the patient was switched to a biventricular assist device (EXCOR; Berlin Heart GmbH, Berlin, Germany) 3 days later as bridge to transplant. Because the pulmonary valve showed moderate regurgitation, it was decided to correct it simultaneously. After implantation of the left ventricular and the right atrial inflow cannulae, the pulmonary artery was opened and the pulmonary valve inspected. A large perforation of one of the leaflets was found to be causing the complication. Reconstruction of the congenitally altered valve appeared not to be feasible. The valve was resected and replaced by a 21-mm biologic prosthesis (Epic; St. Jude Medical, St. Paul, MN) (Figure 1). The pulmonary artery was closed with a patch of bovine pericardium (Figure 2) to increase the diameter for the subsequent placement of the right ventricular outflow cannula (Figure 3). Finally, the aortic cannula was implanted. The post-operative course was uneventful except for a re-sternotomy at Day 11 post-operatively because of a symptomatic pericardial hematoma. Clinically and echocardiographically, there were no thrombotic events associated with the pulmonary valve prosthesis. The patient spent the
waiting time until heart transplantation at home 3 hours away from our center and visited the outpatient clinic every 3 weeks. Six months after biventricular device (BVAD) implantation, the patient underwent successful heart transplantation. He is currently alive and back working. Aortic insufficiency impairs the performance of a LVAD because it creates a shunt through the pump.2 Therefore, several strategies have been followed to eliminate regurgitation through the aortic valve at the time of LVAD implantation, such as repair, valve closure, conventional open and transcatheter replacement.3,4 Pulmonary regurgitation can be assumed to produce a recirculation through a right ventricular assist device (RVAD), similar to aortic
Figure 1 Pulmonary valve bioprosthesis (PV) after implantation into the pulmonary anulus. LVC, left ventricular cannula of the Berlin Heart EXCOR; PA, pulmonary artery; RAC, right atrial cannula of the Berlin Heart EXCOR.
1053-2498/$ - see front matter r 2014 International Society for Heart and Lung Transplantation. All rights reserved. http://dx.doi.org/10.1016/j.healun.2013.10.024
Case Anecdotes, Comments and Opinions
219
Figure 3 The pulmonary cannula of the Berlin Heart EXCOR (PC) after implantation into the pulmonary artery (PA). A part of the patch is visible (P). Ao, ascending aorta.
Disclosure statement The authors have no conflicts of interest to disclose.
References
Figure 2 The patch of bovine pericardium before implantation into the pulmonary artery. Ao, ascending aorta; P, patch; PA, pulmonary artery.
regurgitation in a LVAD. To prevent a shunt through the RVAD, we have replaced the insufficient pulmonary valve simultaneously with the BVAD implantation. This resulted in a regular performance of the device. The algorithm utilized at our center involves treating pulmonary regurgitation similar to aortic insufficiency when a VAD is implanted. Myocardial calcification after orthotopic heart transplantation Aaron Lin, MBChB,a Sally Greaves, FRACP,a Nicky Kingston, FRCPA,b David Milne, FRANZCR,c and Peter Ruygrok, FRACPa From the aGreen Lane Cardiovascular Service; bDepartment of Pathology; and the cDepartment of Radiology, Auckland City Hospital, Auckland, New Zealand.
1. Feldman D, Pamboukian SV, Teuteberg JJ, et al. The 2013 International Society for Heart and Lung Transplantation guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant 2013;32:157-87. 2. Zamarripa Garcia MA, Enriquez LA, et al. The effect of aortic valve incompetence on the hemodynamics of a continuous flow ventricular assist device in a mock circulation. ASAIO J 2008;54:237-44. 3. Park SJ, Liao KK, Segurola R, et al. Management of aortic insufficiency in patients with left ventricular assist devices: a simple coaptation stitch method (Park0 s stitch). J Thorac Cardiovasc Surg 2004;127:264-6. 4. Adamson RM, Dembitsky WP, Baradarian W, et al. Aortic valve closure associated with HeartMate left ventricular device support: technical considerations and long-term results. J Heart Lung Transplant 2011;30:576-82.
Myocardial calcification can be either metastatic or dystrophic. Metastatic calcification refers to calcium deposition in normal tissue due to elevated serum calcium levels and is seen in chronic renal failure, destructive bone lesions and hyperparathyroidism.1,2 Dystrophic calcification occurs in necrotic tissue with normal serum calcium levels and may complicate myocardial infarction, hemorrhage, myocarditis and myocardial fibrosis.3 Early calcification after heart transplantation is exceedingly rare.4,5 Pulmonary
The 2013 ISHLT guidelines for mechanical circulatory support recommend surgical intervention on the aortic valve during left ventricular assist device (LVAD) implantation in patients with more than mild aortic regurgitation.1 However, they do not refer to pulmonary regurgitation in patients who need right ventricular support. Herein we present the first reported case of simultaneous biventricular assist device implantation and pulmonary valve replacement for moderate pulmonary regurgitation. A 47-year-old patient was hospitalized with decompensated biventricular heart failure due to dilated cardiomyopathy. He had a history of pulmonary commissurotomy and infundibular resection at the age of 16 years for congenital infundibular and valvular stenosis of a bicuspid pulmonary valve. Despite treatment with levosimendan, the patient deteriorated further and emergent implantation of a peripheral venoarterial extracorporeal membrane oxygenation (ECMO) was required. After recovery of end-organ function on ECMO, the patient was switched to a biventricular assist device (EXCOR; Berlin Heart GmbH, Berlin, Germany) 3 days later as bridge to transplant. Because the pulmonary valve showed moderate regurgitation, it was decided to correct it simultaneously. After implantation of the left ventricular and the right atrial inflow cannulae, the pulmonary artery was opened and the pulmonary valve inspected. A large perforation of one of the leaflets was found to be causing the complication. Reconstruction of the congenitally altered valve appeared not to be feasible. The valve was resected and replaced by a 21-mm biologic prosthesis (Epic; St. Jude Medical, St. Paul, MN) (Figure 1). The pulmonary artery was closed with a patch of bovine pericardium (Figure 2) to increase the diameter for the subsequent placement of the right ventricular outflow cannula (Figure 3). Finally, the aortic cannula was implanted. The post-operative course was uneventful except for a re-sternotomy at Day 11 post-operatively because of a symptomatic pericardial hematoma. Clinically and echocardiographically, there were no thrombotic events associated with the pulmonary valve prosthesis. The patient spent the
waiting time until heart transplantation at home 3 hours away from our center and visited the outpatient clinic every 3 weeks. Six months after biventricular device (BVAD) implantation, the patient underwent successful heart transplantation. He is currently alive and back working. Aortic insufficiency impairs the performance of a LVAD because it creates a shunt through the pump.2 Therefore, several strategies have been followed to eliminate regurgitation through the aortic valve at the time of LVAD implantation, such as repair, valve closure, conventional open and transcatheter replacement.3,4 Pulmonary regurgitation can be assumed to produce a recirculation through a right ventricular assist device (RVAD), similar to aortic
Figure 1 Pulmonary valve bioprosthesis (PV) after implantation into the pulmonary anulus. LVC, left ventricular cannula of the Berlin Heart EXCOR; PA, pulmonary artery; RAC, right atrial cannula of the Berlin Heart EXCOR.
1053-2498/$ - see front matter r 2014 International Society for Heart and Lung Transplantation. All rights reserved. http://dx.doi.org/10.1016/j.healun.2013.10.024
Case Anecdotes, Comments and Opinions
219
Figure 3 The pulmonary cannula of the Berlin Heart EXCOR (PC) after implantation into the pulmonary artery (PA). A part of the patch is visible (P). Ao, ascending aorta.
Disclosure statement The authors have no conflicts of interest to disclose.
References
Figure 2 The patch of bovine pericardium before implantation into the pulmonary artery. Ao, ascending aorta; P, patch; PA, pulmonary artery.
regurgitation in a LVAD. To prevent a shunt through the RVAD, we have replaced the insufficient pulmonary valve simultaneously with the BVAD implantation. This resulted in a regular performance of the device. The algorithm utilized at our center involves treating pulmonary regurgitation similar to aortic insufficiency when a VAD is implanted. Myocardial calcification after orthotopic heart transplantation Aaron Lin, MBChB,a Sally Greaves, FRACP,a Nicky Kingston, FRCPA,b David Milne, FRANZCR,c and Peter Ruygrok, FRACPa From the aGreen Lane Cardiovascular Service; bDepartment of Pathology; and the cDepartment of Radiology, Auckland City Hospital, Auckland, New Zealand.
1. Feldman D, Pamboukian SV, Teuteberg JJ, et al. The 2013 International Society for Heart and Lung Transplantation guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant 2013;32:157-87. 2. Zamarripa Garcia MA, Enriquez LA, et al. The effect of aortic valve incompetence on the hemodynamics of a continuous flow ventricular assist device in a mock circulation. ASAIO J 2008;54:237-44. 3. Park SJ, Liao KK, Segurola R, et al. Management of aortic insufficiency in patients with left ventricular assist devices: a simple coaptation stitch method (Park0 s stitch). J Thorac Cardiovasc Surg 2004;127:264-6. 4. Adamson RM, Dembitsky WP, Baradarian W, et al. Aortic valve closure associated with HeartMate left ventricular device support: technical considerations and long-term results. J Heart Lung Transplant 2011;30:576-82.
Myocardial calcification can be either metastatic or dystrophic. Metastatic calcification refers to calcium deposition in normal tissue due to elevated serum calcium levels and is seen in chronic renal failure, destructive bone lesions and hyperparathyroidism.1,2 Dystrophic calcification occurs in necrotic tissue with normal serum calcium levels and may complicate myocardial infarction, hemorrhage, myocarditis and myocardial fibrosis.3 Early calcification after heart transplantation is exceedingly rare.4,5 Pulmonary
