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Interactive CardioVascular and Thoracic Surgery 21 (2015) 117–118 doi:10.1093/icvts/ivv071 Advance Access publication 25 March 2015

Cite this article as: Spiliopoulos S, Dimitriou AM, Serrano MR, Guersoy D, Autschbach R, Goetzenich A et al. Percutaneous dilatational tracheostomy following total artificial heart implantation. Interact CardioVasc Thorac Surg 2015;21:117–18.

Percutaneous dilatational tracheostomy following total artificial heart implantation Sotirios Spiliopoulosa,*, Alexandros Merkourios Dimitrioua, Maria Rosario Serranoa, Dilek Guersoya, Ruediger Autschbachb, Andreas Goetzenichb, Reiner Koerfera and Gero Tendericha a b

Department for the Surgical Therapy of End-stage Heart Failure and Mechanical Circulatory Support, Heart- and Vascular Center Duisburg, Duisburg, Germany Department of Thoracic and Cardiovascular Surgery, RWTH University Aachen, Aachen, Germany

* Corresponding author. Department for the Surgical Therapy of End-stage Heart Failure and Mechanical Circulatory Support, Heart- and Vascular Center Duisburg, Fahrner Street 133-135, 47169 Duisburg, Germany. Tel: +49-203-5085402; fax: +49-203-5065403; e-mail: [email protected] (S. Spiliopoulos). Received 1 February 2015; received in revised form 5 March 2015; accepted 9 March 2015

Abstract Coagulation disorders and an immune-altered state are common among total artificial heart patients. In this context, we sought to evaluate the safety of percutaneous dilatational tracheostomy in cases of prolonged need for mechanical ventilatory support. We retrospectively analysed the charts of 11 total artificial heart patients who received percutaneous dilatational tracheostomy. We focused on early and late complications. We observed no major complications and no procedure-related deaths. Early minor complications included venous oozing (45.4%) and one case of local infection. Late complications, including subglottic stenosis, stomal infection or infections of the lower respiratory tract, were not observed. In conclusion, percutaneous dilatational tracheostomy in total artificial heart patients is safe. Considering the well-known benefits of early tracheotomy over prolonged translaryngeal intubation, we advocate early timing of therapy in cases of prolonged mechanical ventilation. Keywords: Artificial heart • Respiratory insufficiency • Tracheostomy

Percutaneous dilatational tracheostomy (PDT) is an established option for the management of critically ill patients requiring prolonged mechanical ventilatory support [1]. In the special subset of patients with end-stage biventricular heart failure requiring total artificial heart (TAH) implantation, PDT is performed under coagulopathic and immune-altered conditions: impaired peripheral perfusion and increased filling pressures in the preoperative setting result in hepatic dysfunction and coagulation disorders [2]. Complement activation and cytokine release resulting from interaction between device surfaces and blood predispose patients to infection and inflammation [3]. With this study, we sought to evaluate the safety of PDT in TAH patients.

METHODS Ethical committee approval was not necessary. Informed patient consent regarding the procedure and the collection and publication of the data was obtained. Between July 2011 and January 2015, PDT was performed in 10 male and 1 female Caucasian patients with a SynCardia-TAH (SynCardia Systems, Inc., Tucson, AZ, USA) due to inability to wean from mechanical ventilation. See Table 1 for patient demographics. PDT was performed with bronchoscopic guidance, at 7 days (median value; range 6–12

days), using a standard PDT set (Tracoe Medical GmbH, Nieder-Olm, Germany) as already described by others [4]. Since all patients were in the ICU, no warfarin was administered.

Patient demographics

Table 1: Patient no.

Age (years)

Sex Underlying disease

INTERMACS profile

Intention to treat

1 2 3 4 5 6 7 8 9 10 11

72 70 66 63 63 51 66 73 61 74 44

F M M M M M M M M M M

1 2 2 1 1 1 2 1 2 1 1

Compassionate Compassionate Compassionate BTT BTT BTT BTT DT BTT DT BTT

ICM ICM Amyloidosis ICM ICM DCM DCM Amyloidosis ICM ICM Massive infarction

M: male; F: female; DCM: dilated cardiomyopathy; ICM: ischaemic cardiomyopathy; DT: destination therapy; BTT: bridge to transplant; INTERMACS: Interagency Registry for Mechanically Assisted Circulatory Support.

© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

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S. Spiliopoulos et al. / Interactive CardioVascular and Thoracic Surgery

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Table 2: Examined variables Patient no.

Indication for tracheostomy

Day performed

Duration of the procedure (min)

INR

PTT (s)

Total platelet count (/μl)

Adverse events

1 2 3 4 5 6 7 8 9 10 11

Cardiac cachexia Cardiac cachexia Cardiac cachexia MOF Recurrent atelectasis MOF MOF Cardiac cachexia Cardiac cachexia ARDS MOF

10 7 7 8 12 12 7 12 10 2 7

10 7 9 15 10 15 10 10 10 15 10

1.5 1.4 1.9 2.2 1.5 2.7 1.3 2.8 1.7 2.2 2.9

60 55 45 60 53 50 48 62 58 57 50

150 000 100 000 197 000 109 000 110 000 168 000 97 000 133 000 125 000 90 000 185 000

None Minor bleeding None Minor bleeding None None Minor bleeding Minor bleeding None Minor bleeding Local infection

ARDS: adult respiratory distress syndrome; MOF: multiorgan failure; INR: international normalized ratio; PTT: partial thromboplastin time.

Heparin was used instead with a target PTT of 50–60 s. Prior to the procedure, intravenous heparin administration was discontinued and severe thrombocytopaenia was corrected.

RESULTS Results of retrospective analysis are listed in Table 2. PDT indications were general weakness due to cardiac cachexia (45.4%), multiorgan failure (36.4%), recurrent left pulmonary total atelectasis (9.1%) and severe respiratory failure on the grounds of an adult respiratory distress syndrome requiring concomitant veno-venous extracorporeal membrane oxygenation (9.1%). Procedural time was 10 min (median value; range 7–15 min). Although the procedure was performed mainly under coagulopathic conditions (International normalized ratio median: 1.9; range: 1.3–2.9/partial thromboplastin time median 55 s; range: 45–62/total platelet count median: 125 000/μl; range: 90 000–197 000/μl), there were no cases of major bleeding requiring surgical intervention. Minor venous oozing (45.4%) and one case of local infection in the tracheostomy site successfully treated with antibiotics were the only early complications observed. There were no procedure-related deaths and no cases of mediastinitis. Following PDT, median duration of ventilation was 20.9 days (range 3.7–98.5). In 1 patient, therapy is still ongoing. In the remaining 10 patients, 4 were weaned from mechanical ventilation, decannulated and finally discharged home (in-hospital stay median: 130 days; range: 114–135). In these patients, late complications, including subglottic stenosis, stomal infection or infections of the lower respiratory tract, were not observed. Not surprisingly, overall mortality was relatively high. This was associated with multiorgan failure, which as stated before [5] is relatively common among TAH patients in need of prolonged ventilatory support.

CONCLUSIONS In this study, we examined the safety of PDT in patients requiring TAH therapy for the treatment of end-stage biventricular heart failure. We demonstrated that despite an extremely coagulopathic and immune-altered state, bleeding and infectious complications are rare. Considering the well-known benefits of early tracheotomy over prolonged translaryngeal intubation [6], we advocate performing PDT at an early stage of therapy in cases of prolonged mechanical ventilation following TAH implantation. Conflict of interest: none declared.

REFERENCES [1] Freemann BD, Isabella K, Lin N, Buchmann TG. A metaanalysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest 2000;118:1412–8. [2] Alvarez AM, Mukherjee D. Liver abnormalities in cardiac diseases and heart failure. Int J Angiol 2011;20:135–42. [3] Thompson LO, Loebe M, Noon GP. What price support? Ventricular assist device induced systemic response. ASAIO 2003;49:518–26. [4] Johnson JL, Cheatham ML, Sagraves SG, Block EF, Nelson LD. Percutaneous dilational tracheostomy: a comparison of single versus multiple dilator techniques. Crit Care Med 2001;29:1251–4. [5] Gregoric ID, Harting MT, Kosir R, Patel VS, Ksela J, Messner GN et al. Percutaneous tracheostomy after mechanical ventricular assist device implantation. J Heart Lung Transplant 2005;24:1513–6. [6] Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB. A prospective, randomized study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 2004;32: 1689–94.