CH‐VAD left ventricular assist implantation combined with the Bentall procedure and coronary artery bypass grafting

Abstract

Left ventricular assist device (LVAD) implantation is an effective alternative treatment to heart transplantation, especially for end‐stage heart failure patients who are ineligible for or unable to await a heart transplant. This report describes a complex and innovative surgery where LVAD implantation was performed alongside multiple concomitant cardiac and aortic procedures. A 62‐year‐old male patient with complicated comorbidities developed acute myocardial infarction and subsequent refractory advanced heart failure. Given his critically ill condition and intractable anatomical malformations, the CH‐VAD left ventricular assist system implantation was performed concomitantly with the Bentall procedure, coronary artery bypass grafting, tricuspid valvuloplasty, and foramen ovale closure. The patient was successfully discharged. This case details the medical decision‐making process and surgical strategy and demonstrates the feasibility of LVAD implantation combined with multiple additional cardiac and aortic procedures in expert cardiac centres. Success relies on experienced cardiac surgeons and a multidisciplinary LVAD Heart Team, ensuring excellence in surgical techniques, preoperative evaluation, post‐operative care, and rehabilitation.

Introduction

Left ventricular assist device (LVAD) implantation is an effective alternative treatment to heart transplantation. But LVAD only assists the heart, not replaces it. In some cases, defects in the heart needed to be fixed. Heart failure is mostly caused by dilated cardiomyopathy, ischaemic heart disease, and valvular disease, while combined aortic disease requiring surgical management is rare. The Bentall procedure is the standard procedure for treating aortic dilatation combined with aortic valve disease, and coronary artery bypass grafting (CABG) is the ‘gold standard’ for treating severe coronary artery disease. In order to make the right heart co-ordinate well with LVAD, reduce aortic regurgitation, and avoid aortic rupture or dissection, we performed LVAD implantation combined with the Bentall procedure, tricuspid valve plasty, foramen ovale closure, and CABG on the patient.

Case report

Case report History of presentation

A 62-year-old male patient (weight 59 kg, height 1.62 m, body surface area 1.7 m²) was admitted to this hospital because of chest tightness and shortness of breath for 4 years and chest pain for 5 days. Four years ago, echocardiography showed severe aortic insufficiency with dilatation of the aortic root and ascending aorta; coronary angiography revealed more than 90% stenosis of three major coronary arteries. Thus, coronary artery bypass grafting (CABG) and the Bentall procedure were recommended but were refused. Five days before admission, he developed persistent chest pain accompanied by shortness of breath, which was exacerbated when the patient was supine. He visited the emergency department. A 12-lead electrocardiogram showed ST-segment elevation in leads V1–V5, III, and avF. B-type natriuretic peptide (BNP) was 2937 pg/mL, and cardiac troponin was 2890.7 pg/mL. He was diagnosed with acute myocardial infarction and heart failure. Dual antiplatelet, anticoagulation, and vasoactive medications were administered, and he was immediately admitted to the Heart Failure Center of our hospital.

Past medical history

The patient had hypertension for 20 years but no history of diabetes mellitus. He had smoked for 40 years, averaging 20 cigarettes per day. He drinks a little alcohol.

Investigations

After admission, echocardiography showed a left ventricular ejection fraction (LVEF) of 23%, severe aortic regurgitation, severe mitral regurgitation, moderate tricuspid regurgitation, and patent foramen ovale. The computed tomographic angiography revealed that the diameter of the aortic root and descending aorta was 55.7 and 23.1 mm, respectively (Figure 1). Coronary angiography revealed total occlusion of the right coronary artery (RCA), the left anterior descending (LAD) coronary artery, and the left circumflex (LCX) coronary artery. Right heart catheterization showed total pulmonary resistance of 3.5 woods, mean pulmonary artery pressure of 14 mmHg, and pulmonary capillary wedge pressure (PCWP) of 8 mmHg.

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Management (medical/interventions)

After medication, the patient still had resting symptoms of heart failure with INTERMACS profile 4. His blood pressure was 116/59 mmHg without inotropes. The serum creatinine was 1.3 mg/dL, the total bilirubin was 0.74 mg/dL, and other end-organ function was stabilized. The patient met the criteria for heart transplantation; however, due to the shortage of donor hearts in China and his critically ill condition, the patient might be at high risk of mortality on the heart transplant waitlist. Our heart team decided to perform left ventricular assist device (LVAD) implantation concomitantly with Bentall, CABG, tricuspid valvuloplasty, and foramen ovale closure.

After performing a median sternotomy, the pericardium was opened, and the aorta was assessed. The right saphenous vein graft (SVG) was harvested. Cardiopulmonary bypass (CPB) was established by cannulation of the femoral vein and the vena cavae. The ascending aorta was cross-clamped, and the heart was arrested. An aortotomy was conducted, the right atrium was opened, and a left ventricular drain cannula was placed through the foramen ovale. HTK solution was infused through the coronary ostium. SVG to LAD and SVG to the posterior descending coronary artery (SVG-PDA) anastomoses were performed. The aortic valve was excised, and then a conduit with four branch grafts (Hemashield Platinum, 26 × 10 × 8 × 8 × 10 mm) and an aortic biological valve (Medtronic, Hancock II Porcine Bioprosthesis, 23 mm) was secured to the annulus. Left and right coronary ostia were anastomosed to the conduit using 5–0 prolene sutures. Three branches of the conduit were closed by suturing, leaving one 10 mm branch for connecting with the outflow graft (from another 10 mm branch of the four-branch graft) of the LVAD (Figure 2A). A distal aortic anastomosis was performed using 4–0 prolene sutures. Through the right atrial incision, a tricuspid annuloplasty ring (Medtronic, contour 3D annuloplasty ring, 30 mm) was secured to the annulus. The apical cuff was sewn to the predetermined position of the apex and reinforced with Teflon felt. The apex was cored, and the pump was placed. With the drainage tube removed, the patent foramen ovale and right atrial incision were sutured using 4–0 prolene sutures. The SVG was anastomosed to the native aorta. The outflow graft of the pump was connected with the branch of the artificial aorta by end-to-end anastomosis (Figure 2B). To our knowledge, this innovative approach to establishing outflow graft had not been attempted before. The artificial vessel and right auricular shunt were wrapped by an aortic aneurysm wall. The aortic cross-clamp was removed, and the patient was rewarmed (Supporting information). While the LVAD provided a pump flow of 4.14 L/min at 2500 rpm, the CPB was terminated. Transesophageal echocardiography showed an inflow cannula pointing to the mitral valve and right heart without tricuspid regurgitation (Figure 3). The CPB time was 316 min, and the aortic cross-clamp time was 241 min. The patient was transferred to the intensive care unit (ICU) in stable condition.

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The patient was extubated on Post-operative Day (POD) 1. He experienced a persistent fever for 20 days after surgery, yet no definitive infection source was identified. Following a multidisciplinary team discussion, drug-induced fever was considered. Consequently, antibiotics were discontinued, which led to a normalization of his temperature, and then rehabilitation was initiated. Post-operative anticoagulation started with intravenous heparin on POD2 when total chest tube output was <40 mL/h, aiming for an activated clotting time (ACT) of 175–200 s. Due to an extended stay in the ICU following comprehensive cardiac surgery, the transition from intravenous to oral anticoagulation was delayed. Warfarin was given on POD20 to achieve a target international normalized ratio (INR) of 2.0–2.5, and aspirin at 100 mg daily was added on POD25. Both medications were maintained throughout the support period. Post-operative blood pressure was managed to maintain a target mean arterial pressure of 70–90 mmHg. The patient was successfully discharged on POD107 without adverse events such as stroke, gastrointestinal bleeding, or arrhythmia (Figure 4A,B). His long-term outcome needed to be followed up on.

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Discussion

Current guidelines recommend that more than mild aortic regurgitation should be addressed at the time of LVAD implantation.^1,2 Techniques for addressing aortic valve insufficiency include closure, repair, or replacement.³ Previous reports have shown that aortic valve closure is associated with decreased overall survival, thrombosis-free survival, and poorer left ventricular function on support.^4,5 In our case, the patient's aortic wall was thin and fragile due to aneurysmal dilatation. Thus, it was unlikely to anastomose the LVAD outflow graft to the aortic wall firmly. Previous studies demonstrated that the morphology of the aortic wall media might be altered in terms of medial degeneration, elastic fibre fragmentation, and medial fibrosis after continuous-flow LVAD support.^6,7 Even though the LVAD outflow graft was barely anastomosed to the native aorta, the patient was likely to die from aortic dissection or rupture after the operation. Therefore, we decided to perform the Bentall procedure simultaneously. Safa Gode et al.^8,9 reported cases of aortic surgery combined with LVAD implantation, but none were as complicated as this one. LVAD only provides mechanical support for the left ventricle; the success of LVAD implantation lies in the right heart function that matches the left heart. Therefore, we also conducted CABG, tricuspid valvuloplasty, and patent foramen ovale closure. These additional procedures are strongly recommended by the guidelines, while intervention for severe mitral regurgitation is not explicitly recommended.² We also believe that mitral regurgitation will disappear after LVAD implantation, so we did not address the mitral valve. The patient underwent a total of five cardiac procedures with a long operative time and high risks. Fortunately, the patient's surgery was completed successfully. Tricuspid valvuloplasty reduced tricuspid regurgitation, coronary artery revascularization enhanced systolic function of the right heart, and patent foramen ovale closure prevented shunts from the left to the right heart. Thus, the patient's right heart co-ordinated well with LVAD. Aortic valve replacement assured enough blood pumped by LVAD into systemic circulation instead of returning to the heart. Besides, mitral regurgitation did disappear after surgery (Figure 3D,F). The artificial aorta was so durable that it was unlikely to rupture or expand while receiving blood from the LVAD. The goal of our surgical strategy was to offer this patient an opportunity to survive and recover well, to regain long-term quality of life on LVAD support, and also to receive a heart transplant in the future.

LVADs have revolutionized the management of advanced heart failure. As is illustrated by this case, when a heart transplant is unavailable for this critically ill patient with complicated anatomical comorbidities, LVAD implantation combined with the Bentall procedure, CABG, tricuspid valvuloplasty, and patent foramen ovale closure offered a feasible solution and mitigated the high mortality risks associated with awaiting a heart transplant. However, there are some prerequisites for completing such a complex surgery. A comprehensive examination and evaluation are needed to assess the urgency of the patient and their capacity to withstand complex procedures. Decision-making should involve an active and collaborative multidisciplinary LVAD Heart Team, including cardiac surgeons, cardiologists, echocardiography specialists, cardiovascular anaesthesiologists, and other specialists. The leading surgeon should be an expert in cardiac and aortic surgery, completing the surgery in less time. Nursing personnel with expertise in post-operative care and rehabilitation of patients with LVAD are also an important asset to the multidisciplinary LVAD Heart Team.

The CH-VAD left ventricular assist system (CH Biomedical, Su Zhou, China) is the latest generation of fully magnetically levitated centrifugal-flow LVAD in China (Figure 4C). In this critically ill case, the CH-VAD pump provided excellent circulatory support without hemocompatibility-related adverse events.

Conclusions

When a heart transplant is unavailable for end-stage heart failure patients with complicated anatomical comorbidities, LVAD implantation combined with multiple additional cardiac and aortic procedures is a feasible strategy in expert cardiac centres with experienced cardiac surgeons and a multidisciplinary LVAD Heart Team. This guarantees not only a high level of surgical technique but also meticulous preoperative evaluation, post-operative care, and rehabilitation for patients with complex heart failure conditions.

Conflict of interest

The authors have nothing to disclose.

Funding

The National Key Research and Development Program of China (2021YFC2501100) will pay for the publication of this article.

References

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