Acta Cardiol Sin 2015;31:249-252 Case Report
doi: 10.6515/ACS20140421E
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
250
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.
251
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.
1. Magovern GJ. Simpson KA. Extracorporeal membrane oxygenation for adult cardiac support: the Allegheny experience. Ann Thorac Surg 1999;68:655-61. 2. Hsu PS, Chen JL, Hong GJ, et al. Extracorporeal membrane oxygenation for refractory cardiogenic shock after cardiac surgery: 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 of the Levitronix CentriMag ventricular assist system for shortterm circulatory support. J Thorac Cardiovasc Surg 2011;141: 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 transplantation: application of the Berlin Heart, Medos and Thoratec ventricular assist devices. J Heart Lung Transplant 2006;25:16-21. 6. Slaughter MS, Rogers JG, Milano CA, et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med 2009;361:2241-51. 7. Fang JC. Rise of the machines-left ventricular assist devices as permanent therapy for advanced heart failure. N Engl J Med 2009;361:2282-5.
CONFLICTS OF INTEREST AND SOURCE OF FUNDING None.
Acta Cardiol Sin 2015;31:249-252
252
doi: 10.6515/ACS20140421E
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
250
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.
251
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.
1. Magovern GJ. Simpson KA. Extracorporeal membrane oxygenation for adult cardiac support: the Allegheny experience. Ann Thorac Surg 1999;68:655-61. 2. Hsu PS, Chen JL, Hong GJ, et al. Extracorporeal membrane oxygenation for refractory cardiogenic shock after cardiac surgery: 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 of the Levitronix CentriMag ventricular assist system for shortterm circulatory support. J Thorac Cardiovasc Surg 2011;141: 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 transplantation: application of the Berlin Heart, Medos and Thoratec ventricular assist devices. J Heart Lung Transplant 2006;25:16-21. 6. Slaughter MS, Rogers JG, Milano CA, et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med 2009;361:2241-51. 7. Fang JC. Rise of the machines-left ventricular assist devices as permanent therapy for advanced heart failure. N Engl J Med 2009;361:2282-5.
CONFLICTS OF INTEREST AND SOURCE OF FUNDING None.
Acta Cardiol Sin 2015;31:249-252
252
