Eur J Cardiothorac Surg 2007;32:807-809. doi:10.1016/j.ejcts.2007.08.016
Copyright © 2007, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Parachute-like technique for off-pump implantation of cardiac support device in isolated and combined procedure
Louis Labrousse*,
Laurent Barandon,
Flora Numis,
Claude Deville
Department of Cardio-Vascular Surgery, Bordeaux Heart University Hospital, Avenue de Magellan, 33604 Bordeaux-Pessac, France
Received 30 March 2007;
received in revised form 7 August 2007;
accepted 10 August 2007.
* Corresponding author. Address: Department of Cardio-Vascular Surgery, Hôpital Haut Lévèque, Avenue de Magellan, 33604 Bordeaux-Pessac, France. Tel.: +33 5 57 65 64 37; fax: +33 5 57 65 81 57. (Email: louis.labrousse{at}chu-bordeaux.fr).
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Abstract
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Cardiac support is a new and promising therapy for refractory heart failure. Only a few previous publications focused on technical implantation of such device. We have developed a new technique that facilitates a consistent and safe implant when the procedure is done without extra-corporeal circulation (ECC). Herein, we report our experience of 60 consecutive CorCap® cardiac support device (Acorn Cardiovascular, USA) implantations off-pump for both isolated and combined implantation.
Key Words: Heart failure surgery
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1. Introduction
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Cardiac support device (CSD) offers a new therapeutic target for patients with refractory heart failure [1–3]. The aim of this polyester-mesh device is to provide end-diastolic support and a counter-pressure on the external part of the ventricles that reduces the transmural pressure and diastolic wall stress and therefore induces a beneficial reverse remodeling process [1–3].
Previously published surgical techniques recommended the use of cardiopulmonary bypass for isolated procedures in order to avoid hemodynamic alterations or arrhythmias [4] and in case of combined procedures in order to facilitate the device implantation [4,5]. However, there is increasing interest in completing even complex procedures off-pump to avoid the morbidity and expense associated with ECC. One of the most challenging aspects of CSD implantation off-pump has been maintaining hemodynamic stability when lifting the heart to place the stay sutures in the atrioventricular (A-V) groove posteriorly. In this report, we describe our technique regarding the off-pump CSD implantation that utilizes a parachute technique that was used on 60 consecutive patients for isolated or combined procedures.
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2. Technique
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The parachute-like technique uses techniques similar to those developed for off-pump CABG [6]. After usual full sternotomy, an inverted T pericardial incision is performed, expanding largely on the left side (with diaphragmatic sheathes sectioned) in order to provide good exposure of the lateral and posterior faces of the heart. Note that an inotropic drug was not used until the device was implanted and that fluid administration was strictly limited to avoid ventricular overload (<500 ml). The heart is then measured to assess circumferential and apex-to-base lengths. Both measurements are used to select the appropriate size on the manufacturer's chart (six sizes) (Video 1). Three to four pericardial stitches lift the apex of the heart (Fig. 1
). The next step is to place 6–8 epicardial 4-0 polypropylene sutures, which are anchored along the posterior part of the left A-V groove and similarly to the border of the device. As this part of the CorCap® is slightly elastic special attention is required to obtain the same distance on the A-V groove and on the border of the device in order to obtain an external containment of the posterior part of the mitral valve. If necessary, gentle right decubitus and Trendelenburg position is applied to improve the surgical field. Then the device is pushed down (Fig. 1) and sutures tightened. During this entire step, even in the largest heart, a stable hemodynamic state is obtained without difficulties. The heart is then removed in its anatomical position and the right and left anterior sutures along the A-V groove are placed. The last step is the fit itself, which is obtained by an anterior suture associated with trimming the excess Dacron fabric (Fig. 2
) (Video 2).
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Fig. 1. Operative view of the heart lifted by pericardial stitches with the first 6–8 posterior stitches, which allows getting the cardiac support device down and around the heart without any hemodynamic compromise. On the chest X-ray note the cardiothoracic ratio at 0.6.
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Fig. 2. Final operative view with the anterior suture followed by combined off-pump CABG with the left internal mammary artery on a left marginal artery. Note that hemodynamic parameters are maintained stable during the whole procedure.
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The final fitting is qualitative in that the surgeon looks for a snug fit in which the CSD lies smoothly on the surface of the heart without any folds, redundancies or scalloping of edges. The proper fitting is confirmed by a ‘tent test’ in which the device, when lifted off the surface of the heart with forceps, quickly reapproximates within 1–2 cardiac cycles. Pre- and postimplant transesophageal echocardiography is performed to ensure that the LV end-diastolic dimension has not been reduced by more than 10% when compared to baseline. Mean implantation time was 28 min (range 17–42). If concomitant CABGs are planned, an off-pump approach using the same exposure techniques [6] is preferentially used (Fig. 2), with 4–6 sutures added around the hole that is cut in the CSD to avoid any risk of friction between the anastomosis and the device. For associated procedures on the arrested heart, the ECC and cardioplegia are performed as usual after the CSD implantation. Similar to off-pump bypass, in case of on-pump bypass a small hole (
1 cm2) is cut in the CSD before the ECC and sutured to the epicardium at the expected anastomosis site. For mitral ± tricuspid repair, left atrial endocardial ablation (maze) and aortic valve replacement, there is no interference of the CSD with the operative field. Therefore the procedure is performed in a usual manner.
Lastly, note that an inotropic drug was not used until the device was implanted and that fluid administration was strictly limited to avoid ventricular overload (<500 ml).
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3. Comment
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From June 2002 to February 2007, this parachute-like CorCap® implant technique was used in 60 consecutive patients who had surgery for refractory heart failure. In 39 patients, concomitant procedure was associated and included on-pump or off-pump CABG, mitral and/or tricuspid repair, endocardial maze ablation and aortic valve replacement. All patients had successful off-pump CSD implantation with a mean LVEDD reduction at 5.2% (from 0 to 9%). No arrhythmia or hemodynamic alteration during the procedure led to convert the implantation to an ‘ECC-assisted’ procedure. Thirty days mortality of the series was 9.5% for the CSD alone group (2 patients out of 21) and 2.5% for the combined procedures (1 patient out of 39). No morbidity or mortality was recorded as device-related.
Early and late follow-up of the patients in this series showed that functional status and cardiac structure (LV size, sphericity and function) improved and that these changes were comparable to the preliminary studies [2,3] and of promising prospect.
Cardiac support is an important innovative therapy for refractory heart failure. As the device has to be fitted by hand in the operating room, a reproducible and reliable technique of implantation, which will make this new device more acceptable by cardiologists and surgeons, is needed. The parachute-like technique allows this, even in case of concomitant procedures, and should be used as the preferred implant technique.
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Appendix A
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Supplementary data
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ejcts.2007.08.016.
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Footnotes
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\#9734; Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005.
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References
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Abstract
1. Introduction
