ARTICLE IN PRESS doi:10.1510/icvts.2007.173146
Interactive CardioVascular and Thoracic Surgery 7 (2008) 524–526 www.icvts.org
Case report - Aortic and aneurysmal
Abdominal aortic aneurysm surgery with mechanical support using the Impella䊛 microaxial blood pump Fadi Farhata,*, Thomas Sassarda, Yassin Attofb, Olivier Jegadena Department of Cardiovascular Surgery B (Pr Jegaden), Ho ˆ pital Cardiovasculaire et Pneumologique Louis Pradel, Universite ´ Claude Bernard, Inserm U886, 28, avenue du doyen Le ´ pine, 69677, Bron Cedex, France b Department of Anesthesia (Pr Lehot), Claude Bernard University, Louis Pradel Hospital, Bron, France
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Received 6 December 2007; received in revised form 30 January 2008; accepted 31 January 2008
Abstract A 50-year-old man with an end-stage cardiac failure was referred to our institution for pre-transplantation assessment. An infrarenal aortic aneurysm (diameter 45 mm) was discovered and progressed (up to 59 mm) over a two-month period. Decision to perform aneurysmectomy with the support of an Impella䊛 Recover LP50 microaxial blood pump was decided regarding the rapid evolution of the disease. The patient had uneventful cardiac-wise during surgery and postoperative period. 䊚 2008 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Aortic surgery; Impella; Microaxial; Assist device
1. Case A 50-year-old man was referred to our institution for an end-stage cardiac failure. Medical history was marked by smoking, alcohol addiction and dyslipidemia. The patient presented three years before myocardial infarcts due to proximal left anterior descending (LAD) artery occlusion. Coronary angiogram revealed multiple vessels stenosis and viability MRI large necrotic anterior and inferior wall segment, with a low left ventricular ejection fraction (LVEF: 18%). A systematic implantation of an internal cardiac defibrillator was performed through the left subclavian vein and the patient was planned for an orthotopic cardiac transplantation. A systematic body scan showed an infrarenal aortic aneurysm measuring 59 mm, starting immediately below the renal arteries (without proximal neck) and extending to the iliac bifurcation. The patient explained that the aneurysm was known for one year, with a recent CT-scan performed two months before showing a diameter of 45 mm. After multidisciplinary discussion, he was scheduled for abdominal aortic surgery with the coverage of an Impella LP50姠 microaxial blood pump. After general anaesthesia, the patient was placed in supine position with a pillow under his kidneys. Arterial monitoring as well as central venous access were performed before surgery. The first step of the procedure was to insert the microaxial pump. A right subclavian incision was made and the subclavian artery exposed. Fifty IUykg of intra*Corresponding author. Tel.: q33 (0) 4 72 35 75 29; fax: q33 (0) 4 72 35 75 32. E-mail address:
[email protected] (F. Farhat). 䊚 2008 Published by European Association for Cardio-Thoracic Surgery
venous heparin was given, then an 8 mm Dacron姠 tube was sutured end-to-side to the artery to allow the introduction of the pump. A guide wire was placed into the left ventricle under fluoroscopy guidance, then the Impella LP50姠 was inserted into the Dacron姠 graft and an occluding plug around the 9Fr driving cable was tied to prevent blood loss during the implantation manoeuvres. The plug allowed the guide wire and the driving cable to slide easily. The pump was pushed towards the ascending aorta and then crossed the aortic valve and its correct positioning was checked using fluoroscopy. After removal of the guide wire, the pump was started to reach progressively a flow of 4.5 lymin. At that moment, a transverse laparotomy was performed and the infrarenal abdominal aorta exposed. It was clamped using a solid body clamp below the renal arteries and opened until the iliac bifurcation. Both iliac arteries were occluded in an endoluminal manner with two 14Fr Foley姠 catheters. A 22 mm Dacron tube (Laboratoires Perouse Implants, Ivry, France) was used to replace the infrarenal aorta. During the suture of the tube, the patient presented a ventricular fibrillation spontaneously resolutive after 20 s. During that period, haemodynamic status remained stable as the pump was delivering a 4 lymin flow. At the end of the distal anastomosis, the proximal aortic clamp was removed after proper de-airing and haemostasis checked (total clamping time 22 min). A Redon catheter was inserted into the retroperitoneal space before the abdomen was closed in a standard manner. The pump was progressively stopped without any inotropic support and removed out of the subclavian artery into the Dacron姠 tube. The prosthesis was cut off, then tied 1 cm close to
ARTICLE IN PRESS F. Farhat et al. / Interactive CardioVascular and Thoracic Surgery 7 (2008) 524–526
the anastomosis with the subclavian artery, and the subclavian incision was closed. The patient was extubated 2 h after admittance into the recovery room. Troponin I at 24 h was 0.04 IUyml. On postoperative day (POD) 5, the patient presented with sustained hyperthermia. Blood cultures revealed methicilline sensible Staphylococcus aureus. The central venous access, still present at that time, was removed and examined, showing the presence of the same micro-organism. A double antibiotherapy (methycilline and gentamycine) was immediately started. Unfortunately, evolution was marked on POD 10 by a septic thrombophlebitis of the right internal jugular vein. The patient underwent thrombectomy of the jugular vein under general anaesthesia, using a Fogarty姠 catheter. A transoesophageal echography (TEE) was performed during the same procedure to eliminate a concomitant endocarditis. Further evolution was uneventful and the patient was discharged home on POD 21. 2. Discussion Chronic heart failure continues to represent a challenge in patients who have to undergo associated surgeries, such as digestive, orthopaedic or abdominal aortic approaches. As a ventricular unloading catheter, the Impella䊛 Recover䊛 microaxial pump is appropriate for temporary circulatory assistance in severe left ventricle (LV) dysfunctions. Impella䊛 Recover䊛 LP50 has been designed for Seldinger technique implantation through femoral artery under local anaesthesia w1x. The device is simple to insert and does not require systemic anti-coagulation. According to the duration of the support, its indications are bridge to recovery, bridge to bridge in a too ill patient for conventional implantable LVADs, and bridge to transplantation when short waiting time is considered w1, 2x. When correctly positioned into the LV, it allows an optimal flow reaching up to 5 lymin. In the case of this patient, the Impella䊛 Recover䊛 LP50 seemed seductive since LVEF was poor, rendering the abdominal aortic replacement very risky. Yet, the implantation of the micro axial pump using a Seldinger technique was impossible in this case. For this reason, we decided to use the right axillary approach. We have recently described this technique for long-term implantations, to allow the patients rehabilitation before weaning w3x. In the present case, the postoperative course was free from cardiac failure and we didn’t note any perioperative myocardial infarct. Yet, the thrombophlebitis of the internal jugular vein is an uncommon complication but the secondary course was satisfactory. In our opinion, the Impella䊛 Recover䊛 LP50 could represent an interesting weapon in the armamentarium of the cardiovascular surgeons in comparable situations. References w1x LaRocca GM, Shimbo D, Rodriguez CJ, Stewart A, Naka Y, Weinberger J, Homma S, Pizzarello R. The Impella Recover LP 5.0 left ventricular assist device: a bridge to coronary artery bypass grafting and cardiac transplantation. J Am Soc Echocardiogr 2006;19:468.e5–7. w2x Garatti A, Colombo T, Russo C, Lanfranconi M, Milazzo F, Catena E, Bruschi G, Frigerio M, Vitali E. Different applications for left ventricular
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mechanical support with the Impella Recover 100 microaxial blood pump. J Heart Lung Transpl 2005;24:481–485. w3x Sassard T, Scalabre A, Bonnefoy E, Sanchez I, Farhat F, Jegaden O. The right axillary artery approach for the Impella Recover LP 5.0 microaxial pump. Ann Thorac Surg, in press.
eComment: Mechanical cardiac support and abdominal vascular surgery Author: Theodor Tirilomis, Department of Thoracic, Cardiac, and Vascular Surgery, University Go ¨ttingen, Go ¨ttingen 37075, Germany doi:10.1510/icvts.2007.173146A Congratulations to Dr. Farhat and colleagues w1x for this excellent idea to perform surgery of abdominal aortic aneurysm (AAA) with mechanical left ventricular support using the Impella microaxial blood pump in a patient with ischemic heart failure and low ejection fraction. Implantation of endovascular prosthesis could be the only alternative treatment in this complicated case. Maybe a new endovascular stent graft device with a short proximal landing zone could have been used. Also, suprarenal stent-graft fixations for infrarenal AAA have been reported with good short- and mid-term results w2x. Implantations of fenestrated stentgrafts for infrarenal AAA with infrarenal anatomy unsuitable for a standard graft have been performed with a low complication rate w3x. Long-term follow-up data are, of course, still required. The presented modified implantation technique of the Impella microaxial blood pump via right subclavian artery through a dacron tube is smart. Although placement of the microaxial pump into the ventricle under fluoroscopy is the standard procedure, I would suggest additionally intraoperative transoesophageal echocardiography (TEE) for control of device position in left ventricle and continuous observation of ventricular contractility and volume filling during surgery. The greatest advantage of the device is its easy handling – the fact that this microaxial pump does not require full systemic anticoagulation. Disadvantageous are the quite high costs, especially for a short-time application, but in cases like the one presented, those costs are justified. However, the described technique gives surgeons the possibility to operate patients with severe heart failure in comparable difficult situations. References w1x Farhat F, Sassard T, Attof Y, Jegaden O. Abdominal aortic aneurysm surgery with mechanical support using the Impella microaxial blood pump. Interact CardioVasc Thorac Surg 2008;7:524–526. w2x Cowie AG, Ashleigh RJ, England RE, McCollum CN. Endovascular aneurysm repair with the Talent Stent-Graft. J Vasc Interv Radiol 2003;14: 1011–1016. w3x Scurr JRH, Brennan JA, Gilling-Smith GL, Harris PL, Vallabhaneni SR, McWilliams RG. Fenestrated endovascular repair for juxtarenal aortic aneurysm. Br J Surg 2008;95:326–332.
eComment: Abdominal aortic aneursym repair: endovascular treatment or surgical repair in critically unstable patients Authors: Dilek Erer, Harefield Hospital/Parkwood House, Hill End Road, Harefield, Middlesex, UB9 6JH, UK; Arup K. Ghosh, Saleem Haj Yahia doi:10.1510/icvts.2007.173146B We read with interest the paper by Farhat et al. in which they presented abdominal aortic aneurysm surgery in a hemodynamically unstable patient with the mechanical support using the Impella microaxial blood pump w1x. We have only one simple concern: What was the contraindication for endovascular treatment? From our point of view, since the patient did not have a contraindication (e.g. iliofemoral stenosis or angulation or approximity to the visceral arteries; i.e. it was possible to clamp the aorta infrarenally), endovascular stent graft repair of the aneurysm would be very appropriate rather than such a challenging procedure beyond all discussions about endovascular treatment and whether it should be done or not w2–5x. References w1x Farhat F, Sassard T, Attof Y, Jegaden O. Abdominal aortic aneurysm surgery with mechanical support using the Impella䊛 microaxial blood pump. Interact CardioVasc Thorac Surg 2008;7:524–526.
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w2x Eliason JL, Upchurch GR Jr. Endovascular abdominal aortic aneurysm repair. Circulation 2008;117:1738–1744. w3x Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5: 491–499. w4x Alpagut U, Ugurlucan M, Kafali E, Surmen B, Sayin OA, Guven K, Dayioglu E, Rozanes I, Onursal E. Endoluminal stenting of mycotic
saccular aneurysm at the aortic arch. Tex Heart Inst J 2006;33:371– 375. w5x Baumgart D, Eggebrecht H, Herold U, Kuehl H, Piotrowski J, Niebel W, Jakob HG, Erbel R. Underlying aortic pathology and clinical health status determine success of endovascular stent-grafting for descending thoracic aortic disease. Catheter Cardiovasc Interv 2006;67:527– 534.
