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J Thorac Cardiovasc Surg 2003;126:2100-2101
© 2003 The American Association for Thoracic Surgery
Brief communication |
a Department of Cardiothoracic Surgery, Hahnemann University Hospital, Drexel University, Philadelphia, Pa, USA
Received for publication January 17, 2003; accepted for publication July 22, 2003.
* Address for reprints: Louis E. Samuels, MD, Lankenau Hospital, MSB #280, 100 Lancaster Ave, Lancaster, PA 19096, USA
samuelsle{at}aol.com
The Abiomed BVS 5000 (Abiomed, Inc, Danvers, Mass) is an extracorporeal pneumatic ventricular assist device (VAD) that has been used in a variety of acute cardiac conditions.1 The purpose of this report is to describe the use and cannulation strategy of the BVS 5000 VAD as a bridge to transplantation in a case of unrepaired postinfarction ventricular septal defect (VSD).
Clinical summary
A 62-year-old American man with a history of coronary artery disease had a myocardial infarction while in the Dominican Republic on September 6, 2001. On September 11, 2001, he became hypotensive from reinfarction. Physical examination revealed a new heart murmur. An echocardiogram showed a posterior ventricular VSD. He was given intravenous dopamine and prepared for transfer to the United States for further management. As a result of the World Trade Center attack, air transportation was suspended. On September 13, 2001, permission was granted for an emergency flight to Philadelphia. The patient was in cardiogenic shock with multiple organ system failure. He was intubated, he was given additional inotropic and vasoconstrictive drugs, and an intra-aortic balloon pump was inserted. The catheterization showed severe-triple vessel coronary artery disease (poor runoff) with moderate pulmonary hypertension and a large posterior VSD. The right atrial, right ventricular, and pulmonary artery saturations demonstrated a shunt at the ventricular level (Table 1). The patient was transferred to the operating room for management.
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After the operation, the patient awoke with an intact neurologic status and stable vital signs. He remained on VAD support for 8 weeks, with improvement in hepatic function. Although the renal function improved, the creatinine clearance was poor. The patient underwent intermittent dialysis through side access ports on the right VAD tubing. Assessment of cardiac recovery was performed with serial echocardiograms, demonstrating persistent severe biventricular failure. The decision was made to list the patient for heart and kidney transplantation. On November 12, 2001, the patient underwent successful double organ transplantation. The postoperative course was uneventful, with no major complications. The patient was discharged to a rehabilitation center for several months of recovery. He was then discharged to home and remains alive and well more than 1 year later.
Discussion
The management of postinfarction VSD remains a therapeutic challenge. Surgical mortality remains high, and initial repairs may be plagued by persistent heart failure, VSD recurrence, and arrhythmia.2 As such, this entity continues to be the subject of cardiothoracic surgical debate regarding the timing and type of surgical repair.
One novel approach to this entity includes the use of a ventricular assist device (VAD) for cardiac support, circulatory stability, and maintenance of end-organ perfusion. The role of the VAD may be as an adjunct to an attempted repair. In this scenario, the postinfarct VSD is repaired, coronary bypass grafting is performed, and the VAD is placed for ventricular unloading and maintenance of adequate cardiac output. The use of implantable VADs for this condition was described by Faber and colleagues3 with the HeartMate (Thoratec Laboratories, Pleasanton, Calif) and Novacor (WorldHeart Corp, Ottawa, Ontario, Canada) systems. Another scenario, however, is to place the VAD without attempting an initial repair. The rationale behind this approach is to avoid operating on fresh infarct and to establish prompt circulatory control. The BVS 5000 VAD has the advantage that it can be placed with or without cardiopulmonary bypass. In addition, inflow to the VAD can be easily accomplished at the atrial level. This is an ideal cannulation strategy for a VSD, in which it is important to avoid a shunt at the ventricular level. As demonstrated in our case, mechanical cardiac support was successful in restoring hemodynamic stability and reversal of multiorgan system failure.
In conclusion, the postinfarction VSD may be managed in a variety of ways. This case demonstrates the novel use of the BVS 5000 VAD with biatrial cannulation for the uncorrected postinfarction VSD as a bridge to transplantation.
References
This article has been cited by other articles:
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  L. Conradi, H. Treede, J. Brickwedel, and H. Reichenspurner Use of initial biventricular mechanical support in a case of postinfarction ventricular septal rupture as a bridge to surgery. Ann. Thorac. Surg., May 1, 2009; 87(5): e37 - e39. [Abstract] [Full Text] [PDF]
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 A. A. Pitsis, T. G. Kelpis, A. N. Visouli, G. Bobotis, G. S. Filippatos, and D. T. Kremastinos Left ventricular assist device as a bridge to surgery in postinfarction ventricular septal defect. J. Thorac. Cardiovasc. Surg., April 1, 2008; 135(4): 951 - 952. [Full Text] [PDF]
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 A. K. Agnihotri, J. C. Madsen, and W. M. Daggett Jr Surgical Treatment of Complications of Acute Myocardial Infarction: Postinfarction Ventricular Septal Defect and Free Wall Rupture Card. Surg. Adult, January 1, 2008; 3(2008): 753 - 784. [Full Text]
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