Percutaneous tracheostomy after mechanical ventricular assist device implantation.

BACKGROUND: Several studies have shown that percutaneous dilational tracheostomy (PDT) is safe and cost-effective for patients recovering from surgery that requires a median sternotomy. We report our experience with PDT in patients receiving mechanical cardiac assistance. METHODS: We reviewed the medical records of all patients who underwent ventricular assist device implantation at our institution between July 2000 and July 2003, and who subsequently required long-term ventilatory support during the same hospital admission. Data obtained from the records included demographic and biometric information, primary diagnosis, early (< or =30days) and late (>30days) complications, date and cause of death, type of anti-coagulation used at the time of tracheostomy, and various coagulation measures. RESULTS: Thirty-one consecutive patients (29 men, 2 women; mean age, 56 years) had PDT after ventricular assist device implantation. Four minor complications occurred among 3 of the patients (10%), including 3 early complications (2 peristomal oozing and 1 peristomal cellulitis) and 1 late complication (recurrent peristomal cellulitis), none of which affected long-term outcome. No major adverse events, long-term complications, or deaths resulted from the PDT procedure. CONCLUSIONS: PDT is feasible for patients with mechanical support devices who require long-term ventilatory support. Although some of these patients are coagulopathic, our results indicate that PDT is safe and effective in this challenging patient population.

Total circulatory support with an LVAD in an adolescent with a previous Fontan procedure.

We report the case of a 14-year-old boy who developed ischemic contracture of the heart after open heart surgery to correct complex congenital heart disease. Because he had no cardiac function, an extracorporeal, continuous-flow device was used to support him until he was transferred to our institution. Shortly after his arrival, an implantable, long-term left ventricular assist device was implanted. The univentricular pump provided total cardiac support for this critically ill patient. After normalization of end-organ function, the patient underwent successful orthotopic cardiac transplantation.

Posttransplant off-pump coronary bypass and laser revascularization in a Jehovah's Witness.

A 57-year-old man, who had received a heart transplant 14 years earlier, underwent coronary artery bypass grafting and transmyocardial laser revascularization for left main, left anterior descending, and circumflex coronary artery disease. The procedures were performed through a left thoracotomy incision without cardiopulmonary bypass. Because the patient was of the Jehovah's Witness faith, no blood or blood products were transfused.

Orthotopic heart transplantation in a patient with D-transposition of the great arteries: after a Mustard procedure.

During heart transplantation, the atrial septum is most often used to reconstruct the right atrial reservoir. We report the case of a patient with corrected D-transposition of the great arteries who underwent successful cardiac transplantation despite the lack of an atrial septum. We then used the donor heart's atrial septum for the roof of the left atrium and used the recipient's left atrium for the back wall of the left atrium. The outcome was a more anatomically positioned transplanted heart, which avoided the duplication of the right and left atria that occurs in conventional orthotopic transplantation and that often leads to left-lower-lobe atelectasis and tricuspid regurgitation. This method of orthotopic transplantation should be considered for, but not limited to, the growing number of adults with congenital heart disease who require heart transplantation.

Left ventricular assist device implantation in a patient with congenitally corrected transposition of the great arteries.

Congenitally corrected transposition of the great arteries (ccTGA) is a rare anomaly characterized by atrioventricular and ventriculo-arterial discordance and several other malformations that eventually lead to heart failure. We describe the case of a 53-year-old woman with ccTGA and aortic insufficiency who was a candidate for heart transplantation due to end-stage congestive heart failure. Her condition deteriorated before a suitable donor heart could be found; therefore, we placed a left ventricular assist device in the right (systemic) ventricle. Concomitantly, we removed the aortic (systemic) valve, closed the aortic annulus with a bovine pericardial patch, and repaired the mitral valve. The patient recovered uneventfully and was discharged from the hospital 2 months postoperatively. She underwent cardiac transplantation approximately 6 months later and continued to do well after 18 months.

Superior vena caval bypass using the superficial femoral vein for treatment of superior vena cava syndrome.

We present the case of a 71-year-old woman who had benign, symptomatic, superior vena cava syndrome that was treated with open surgical bypass using the superficial femoral vein. The patient had an uneventful hospital course and experienced relief of her symptoms. We conclude that the superficial femoral vein is an acceptable bypass conduit for open surgical management of superior vena cava syndrome.

HeartMate vented-electric left ventricular assist system: technique for intrathoracic or intraperitoneal implantation via a left thoracotomy.

The HeartMate vented-electric left ventricular assist system (Thoratec Corp., Woburn, MA) has become widely accepted as a temporary bridge to transplantation. We describe a left thoracotomy technique in 3 patients for implanting this pump intrathoracically or intraperitoneally. In all 3 cases, long-term pump function was satisfactory. For HeartMate implantation, the left thoracotomy approach may be particularly useful when previous median sternotomies, coupled with the severe debilitation posed by chronic heart failure and hepatic dysfunction with resultant coagulopathy, would greatly increase the mortality and morbidity of a redo median sternotomy.

Hemodynamic support with a percutaneous left ventricular assist device during stenting of an unprotected left main coronary artery.

Coronary artery bypass grafting prolongs survival in patients with left main coronary artery stenosis. However, this benefit is denied to patients who refuse the procedure or who are poor surgical candidates due to comorbid conditions. We describe a novel technique for the percutaneous revascularization of stenosis in an unprotected left main coronary artery in high-risk patients. The TandemHeart, a percutaneously inserted left ventricular assist device, was used to provide periprocedural hemodynamic support during angioplasty and stenting of an unprotected left main coronary artery for stenosis in a 70-year-old woman. The device was removed immediately after the procedure, and the patient was discharged from the hospital on the 2nd postprocedural day. The potential advantages of angioplasty with the support of percutaneous left ventricular assist devices in high-risk patients are discussed.

Congenital absence of anterior pericardium at left ventricular assist device implantation.

We report a case of congenital absence of the anterior pericardium in a 41-year-old man who was undergoing implantation of a left ventricular assist device for treatment of congestive heart failure.

Sarcoma metastatic to the right ventricle: surgical intervention followed by prolonged survival.

Malignant tumors that metastasize to the heart pose a formidable therapeutic challenge. Recent advances in surgical treatment have improved the management and prognosis of patients with cardiac metastases. We report the case of a 45-year-old man who had a high-grade pleomorphic sarcoma of the right ventricle. We completely resected the neoplasm, reconstructed the right ventricle, and replaced the mitral valve. Upon late follow-up, 67 months (5.6 years) later, the patient was alive and well. This case shows that aggressive surgical management of malignant disease metastatic to the heart can enable prolonged survival.

Off-pump coronary artery bypass grafting and transmyocardial laser revascularization via a left thoracotomy.

Off-pump coronary artery bypass grafting may be combined with adjunctive transmyocardial laser revascularization to optimize revascularization. This approach may be advantageous for high-risk patients, particularly those having undergone previous sternotomies. From October 2000 through May 2001, 17 patients (9 women and 8 men) underwent off-pump coronary artery bypass grafting and transmyocardial laser revascularization via a left thoracotomy. The patients had a mean age of 63 years and a mean ejection fraction of 0.33. All but 1 patient had undergone previous coronary surgery. In each patient, the heart was approached via a left thoracotomy through the 5th intercostal space, and 37 transmural channels, 1 mm in diameter, were each created with a single pulse of the carbon dioxide laser. Coronary artery bypass grafting was then performed with left internal thoracic artery or saphenous vein grafts. The follow-up period ranged from 2.1 to 9.3 months (mean, 6.2 months). The patients received 28 bypass grafts (mean, 1.6 grafts). Postoperatively, 2 patients required inotropic support. On day 8, 1 patient died of ventricular fibrillation. After a mean hospitalization of 7.7 days, the remaining patients were discharged, free of angina. At follow-up examination after a mean of 6 months (range, 2-9 months), 15 patients remained free of angina and one had mild angina. None had required further hospitalization. Performed via a left thoracotomy, off-pump coronary artery bypass grafting plus transmyocardial laser revascularization yielded an acceptable mortality rate, no major morbidity, and substantial angina relief in this carefully selected group of challenging, high-risk patients.