Correspondence

Combined Aortic Surgery and Implantation of a Left Ventricular Assist Device

N Engl J Med 2002; 346:711February 28, 2002

Article

To the Editor:

There is no clearly established strategy for the treatment of a patient with cardiomyopathy and a symptomatic aneurysm of the thoracic aorta. We report the successful use of an approach combining aortic surgery and the implantation of a left ventricular assist device.

Chest pain developed in a 36-year-old heart-transplant candidate with Marfan's syndrome, terminal heart failure, and chronic type B aortic dissection. He had a history of multiple aortic and cardiac surgical procedures, including prosthetic replacement of the ascending aorta, partial replacement of the aortic arch, and aortic- and mitral-valve replacement. He had had recurrent episodes of cardiac decompensation because of cardiomyopathy. The left ventricular ejection fraction was only 15 percent, and the left ventricular end-diastolic diameter was 87 mm, indicating the need for the implantation of a left ventricular assist device. Because of the development of acute progression (maximal diameter, 80 mm) of the chronic dissecting aneurysm involving the distal part of the aortic arch and the entire descending thoracic aorta, increased chest pain, and the risk of aortic rupture, the patient required urgent surgery to treat both aortic and myocardial problems. In view of recurrent episodes of myocardial decompensation and myocardial insufficiency, it was presumed that he could not survive isolated aortic surgery, and the implantation of the assist device alone would have left him with a risk of aortic rupture. Therefore, we decided to implant a left ventricular assist device during the aortic procedure.

Both procedures were performed through a left anterolateral thoratocomy, with cardiopulmonary bypass with femorofemoral cannulation. The distal part of the aortic arch and complete descending thoracic aorta were replaced with a Dacron graft (diameter, 24 mm) with the use of deep hypothermia, regional circulatory arrest, and regional perfusion. The left ventricle was then supported with a paracorporeal assist device. An 80-ml pump was connected to the left ventricular apex and to the descending aortic graft with the use of standard inflow and outflow cannulas1 (Figure 1Figure 1Combined Surgical Approach Involving Replacement of the Descending Thoracic Aorta with a Graft and the Implantation of a Paracorporeal Left Ventricular Assist Device.). The procedure was completed uneventfully, and the patient recovered well. He has now been waiting for an appropriate donor heart for almost five months.

Although urgent, lifesaving surgery was needed because of the imminent risk of aortic rupture, terminal cardiac insufficiency precluded the use of an open surgical procedure. Treatment with a less invasive endovascular stent–graft2 was not possible because of the extensive aortic disease. Combining surgery for both cardiac and aortic abnormalities proved successful in this case of an otherwise inoperable condition.

Miralem Pasic, M.D., Ph.D.
Manfred Hummel, M.D.
Roland Hetzer, M.D., Ph.D.
Deutsches Herzzentrum Berlin, D-13353 Berlin, Germany
pasic@dhzb.de

2 References

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   Pasic M, Bergs P, Henning E, Loebe M, Weng Y, Hetzer R. Simplified technique for implantation of a left ventricular assist system after previous cardiac operations. Ann Thorac Surg 1999;67:562-564
   CrossRef | Web of Science | Medline

2. 2

   Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340:1546-1552
   Full Text | Web of Science | Medline

Citing Articles (4)

Citing Articles

1. 1

   Koji Takeda, Umraan Ahmad, Sukit Chris Malaisrie, Richard Lee, Patrick M. McCarthy, Edwin C. McGee. (2012) Successful implantation of HeartWare HVAD left ventricular assist device with concomitant ascending and sinus of valsalva aneurysms repair. Journal of Artificial Organs
   CrossRef

2. 2

   Ivan Netuka, Jiri Maly, Ondrej Szarszoi, Ivo Skalsky, Hynek Riha, Tomas Kotulak, Jiri Novotny, Michal Hulman, Jan Pirk. (2009) Single-stage Extensive Chronic Type A Dissecting Aortic Aneurysm Repair and Continuous-flow Ventricular Assist Device Implantation. The Journal of Heart and Lung Transplantation 28:5, 523-526
   CrossRef

3. 3

   Christoph Knosalla, Yu-guo Weng, Robert Hammerschmidt, Miralem Pasic, Isabela Schmitt-Knosalla, Onnen Grauhan, Michael Dandel, Hans B. Lehmkuhl, Roland Hetzer. (2007) Orthotopic Heart Transplantation in Patients With Marfan Syndrome. The Annals of Thoracic Surgery 83:5, 1691-1695
   CrossRef

4. 4

   William A. Smith, Patrick McCarthy, Kiyotaka Fukamachi. (2003) Reading and Writing in the Field of Mechanical Circulatory Support. ASAIO Journal 49:5, 511-512
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