ORIGINAL ARTICLE Braz J Cardiovasc Surg 2020;35(4):477-83 Left Ventricular Assist Device Implantation and Concomitant Dor Procedure: a Single Center Experience Andreas Schaefer1*, MD, MHBA; Yvonne Schneeberger1*, MD, MHBA; Liesa Castro1, MD; Bjoern Sill1, MD; Yousuf Alassar1, MD; Meike Rybczynski2, MD; Markus J Barten1, MD; Hanno Grahn2, MD; Hermann Reichenspurner1, MD, PhD; Sebastian A Philipp3**, MD; Alexander M Bernhardt1**, MD DOI: 10.21470/1678-9741-2019-0349 Abstract Objective: Left ventricular assist device (LVAD) implantation patient was lost due to intentional disconnection of the driveline. with concomitant Dor plasty is only reported anecdotally. We herein One patient underwent heart transplantation on postoperative aimed to describe our experience with LVAD and concomitant Dor day 630. The remaining three patients are still on device with procedures and describe long-term outcomes of this special subset sufficient flow; pump thromboses were successfully managed by of heart failure patients. lysis therapy in one patient. Methods: Between January/2010 and December/2018, 144 Conclusion: LVAD implantation with concomitant Dor patients received LVAD therapy at our institution. Of those, five procedure is feasible, safe, and occasionally performed in patients patients (80% male, 60.4±7.2 years) presented with an apical with ischemic cardiomyopathy. Major advantages are prevention aneurysm and received concomitant Dor plasty. Apical aneurysms of thromboembolism and facilitation of LVAD placement by presented diameter between 75 and 98 mm, with one impending improving pump stability and warranting midventricular, coaxial rupture. alignment of the inflow cannula. In long-term follow-up, no Results: Procedural success was achieved in all patients. No adverse event associated with Dor plasty was observed. unplanned right ventricular assist device implantation occurred. Keywords: Heart Transplantation. Heart Failure. Thrombosis. Furthermore, no acute 30-day mortality was seen. In follow-up, one Thromboembolism. Aneurysm. Cardiomyopathies. INTRODUCTION premature death while awaiting transplantation[5]. Patients Due to limited availability of donor organs for heart selected for LVAD implantation usually suffer from significant transplantation, implantation of intracorporal miniaturized left comorbidities which may (e.g., renal failure and lung disease) ventricular assist devices (LVAD) became clinical daily routine or may not be associated with the underlying cardiac disease[6]. for treatment of end-stage heart failure (HF), with the number Especially concomitant cardiac conditions, like valve stenosis/ of procedures increasing annually[1,2]. HF remains the most regurgitation, coronary heart disease, or right ventricular failure, common reason for hospital admission in the United States and require additional procedures during LVAD implantation. Western Europe, and therefore, it can be anticipated that the Here, outcomes were reported for concomitant valve repair/ number of LVAD implantations will further increase. Currently, replacement (aortic, mitral, tricuspid), patent foramen ovale 100% of patients in need for destination therapy, registered in closure, or implantation of a temporary right ventricular the Interagency Registry for Mechanically Assisted Circulatory assist device (RVAD)[7-9]. Another precondition which may be Support (INTERMACS), receive continuous-flow (CF) pumps[3,4]. complicating to LVAD surgery is a left ventricular aneurysm in These miniaturized CF pumps improve the outcome of patients patients with ischemic cardiomyopathy (ICMP) and status post with end-stage HF in terms of symptoms, hospitalization, and (s/p) transmural myocardial infarction. Here, LVAD insertion is 1Department of Cardiovascular Surgery, University Heart and Vascular Center Correspondence Address: Hamburg, Hamburg, Germany. Andreas Schaefer 2Department of General and Interventional Cardiology, University Heart and https://orcid.org/0000-0001-7304-6083 Vascular Center Hamburg, Hamburg, Germany. University Heart and Vascular Center Hamburg 3Department of Cardiology and Intensive Care Medicine, Elbe Clinic, Stade, Germany. Martinistraße 52, Hamburg, Germany Zip Code: D-20246 *AS and YS contributed equally to this work. E-mail: [email protected] **SAP and AMB contributed equally to this work. This study was carried out at the University Heart and Vascular Center Hamburg, Article received on September 11th, 2019. Hamburg, Germany. Article accepted on September 26th, 2019. 477 Brazilian Journal of Cardiovascular Surgery Schaefer A, et al. - LVAD and Dor Plasty Braz J Cardiovasc Surg 2020;35(4):477-83 Abbreviations, acronyms & symbols AKI = Acute kidney injury ICMP = Ischemic cardiomyopathy AV = Aortic valve INTERMACS = Interagency Registry for Mechanically Assisted BMI = Body mass index Circulatory Support BTR = Bridge to recovery LDH = Lactic acid dehydrogenase BTT = Bridge to transplantation LV = Left ventricle CABG = Coronary artery bypass grafting LVAD = Left ventricular assist device CF = Continuous-flow LVEDD = Left ventricular end-diastolic diameter COPD = Chronic obstructive pulmonary disease LVEF = Left ventricular ejection fraction CPB = Cardiopulmonary bypass MCS = Mechanical circulatory support CRP = C-reactive protein MI = Mitral insufficiency CVVHD = Chronic venovenous hemofiltration MV = Mitral valve DT = Destination therapy PCI = Percutaneous coronary intervention ECMO = Extracorporeal membrane oxygenation RVAD = Right ventricular assist device EVPP = Endoventricular patch plasty RVP = Right ventricular pressure GOLD = Global Initiative for Chronic Obstructive Lung Disease s/p = Status post GOT = Glutamate-oxaloacetate transaminase STEMI = ST-elevation myocardial infarction GPT = Glutamate-pyruvate transaminase TAPSE = Tricuspid annular plane systolic excursion HF = Heart failure Thr = Thrombus HTx = Heart transplantation TI = Tricuspid insufficiency IABP = Intra-aortic balloon pump VT = Ventricular fibrillation ICD = Implantable cardioverter defibrillator compounded by a thin apical myocardium, and left ventricular opened. Subsequently, thrombotic material was removed, and thrombus formation is often present[10]. To facilitate CF pump the edge of vital myocardium was identified. Here, a reinforcing insertion and placement and to prevent thromboembolism in running 2-0 Prolene (Ethicon Inc., Somerville, NJ, USA) suture such cases, concomitant endoventricular patch plasty (EVPP) buttressed with Teflon felt was performed. Simultaneously, the (Dor procedure[11]) should be taken into consideration. However, HVAD ring was sewed in a Vascutek (Terumo Co., Shibuya, Tokyo, these combined procedures are only described anecdotally with Japan) or pericardial patch utilizing a running 3-0 Prolene suture. documentation of acute and perioperative outcomes[12]. We Then, the patch was attached to the neoapex with interrupted herein describe our experience with combined LVAD and Dor felt-pleged 3-0 Prolene sutures and the patch was furthermore procedures with an emphasis on long-term follow-up. secured by a subsequent performed running 2-0 Prolene suture comprising transmural stitches of vital myocardium. Further METHODS procedural steps followed institutional routines including HVAD pump insertion and alignment, tunneling of the driveline, and Patients attaching of the outflow graft to the ascending aorta. Crucial Between January/2010 and December/2018, 144 patients steps of the described procedure are depicted in Figure 1. received LVAD therapy for end-stage HF at our institution. Of those, five patients (5/144, 3.5%) presented with apical aneurysms Follow-Up and received concomitant Dor plasty during LVAD implantation. Baseline, intraprocedural, and follow-up data were collected All five patients presented with ICMP, s/p ST-elevation myocardial and entered into a dedicated standardized database. Clinical infarction, and severely reduced left ventricular ejection fraction. endpoints were death and heart transplantation. Mean follow- Four patients had a history of multiple percutaneous coronary up time was 547.6±473.1 days. Data are presented as absolute interventions and one patient underwent multiple coronary numbers and percentages for categorical variables and mean artery bypass grafting procedures. values and standard deviation for continuous variables, unless stated otherwise. Ventricular Assist Device Implantation and Concomitant Endoventricular Patch Plasty RESULTS In all patients, a HeartWare HVAD (Medtronic, Minneapolis, Baseline Demographics MN, USA) device was implanted through median sternotomy with support of cardiopulmonary bypass (CPB) to unload the left Overall, five patients (80% male, 60.4±7.2 years) received ventricle. After luxation of the heart, the left ventricular apex was concomitant EVPP during LVAD implantation for apical aneurysm 478 Brazilian Journal of Cardiovascular Surgery Schaefer A, et al. - LVAD and Dor Plasty Braz J Cardiovasc Surg 2020;35(4):477-83 Fig. 1 – Intraoperative pictures of left ventricular assist device (LVAD) implantation with concomitant Dor plasty. Intraoperative course of patient n. 5: large left ventricular apex aneurysm after median sternotomy (A), opening of the apex (B) and removal of a large thrombus (Thr) (C), adaptation of the LVAD sewing ring to a patch (D), apex reconstruction with the patch (E), and implantation of the LVAD device (F). LV=left ventricle and end-stage HF at our institution. Of those, three patients LVAD implantation with concomitant EVPP was performed as