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Use of polytetrafluoroethylene vascular graft to cover the kinking protector of left ventricular assist device facilitates later pump exchange

2014; Elsevier BV; Volume: 148; Issue: 2 Linguagem: Inglês

10.1016/j.jtcvs.2014.03.034

1097-685X

Evgenij Potapov, Roland Hetzer, Thomas Krabatsch,

Cardiac Arrest and Resuscitation

The HeartWare left ventricular assist device (HVAD; HeartWare Inc, Framingham, Mass) is a reliable tool for the treatment of end-stage heart failure. To date, more than 5000 pumps have been implanted in patients worldwide with excellent clinical results, and the numbers are increasing every year. However, some patients require a pump exchange during support, mostly because of thrombosis and less frequently for cable damage.1Potapov E.V. Stepanenko A. Kaufmann F. Henning E. Vierecke J. Lehmkuhl E. et al.Thrombosis and cable damage in the HeartWare pump: clinical decisions and surgical technique.Asaio J. 2013; 59: 37-40Crossref PubMed Scopus (26) Google Scholar The surgical technique has been described.1Potapov E.V. Stepanenko A. Kaufmann F. Henning E. Vierecke J. Lehmkuhl E. et al.Thrombosis and cable damage in the HeartWare pump: clinical decisions and surgical technique.Asaio J. 2013; 59: 37-40Crossref PubMed Scopus (26) Google Scholar, 2Sajjad M. Butt T. Oezalp F. Siddique A. Wrightson N. Crawford D. et al.An alternative approach to explantation and exchange of the HeartWare left ventricular assist device.Eur J Cardiothorac Surg. 2013; 43: 1247-1250Crossref PubMed Scopus (14) Google Scholar Dissecting the plastic rings of the kinking protector from the epicardium is a major surgical challenge during pump exchange because of severe epicardial adhesions and ingrowth of tissue between the plastic rings. This step is time-consuming and may lead to bleeding or damage to the right ventricle. There is only one way to avoid this risk—by not dissecting the kinking protector from the heart surface. One possibility is to resect only the upper parts of the first 7 to 8 plastic rings, because these upper parts are not attached to the epicardium, and then to remove the graft from the kinking protector. The disadvantage of this approach is that unless a new kinking protector is attached after pump exchange, the outflow graft remains partially unprotected. A more elegant option is to avoid adhesions around the kinking protector altogether by pulling a 20-mm diameter polytetrafluoroethylene (Gore-Tex; WL Gore & Associates, Inc, Newark, Del) graft over the kinking protector before implantation of the pump (Figure 1, Figure 2). To avoid migration of the polytetrafluoroethylene (Gore-Tex) graft, we attach it to the pump housing or the first plastic ring of the kinking protector using 3-0 Prolene suture. In addition, so that it can be easily identified, the fixation screw is covered with a silicon tube (1 mm diameter, 2 cm long) usually used to cover the branches of a mosquito clamp.Figure 2Operating field (redo median sternotomy) before closure of the sternum with polytetrafluoroethylene (Gore-Tex) graft pulled over the kinking protector and outflow graft.View Large Image Figure ViewerDownload Hi-res image Download (PPT) During pump exchange, the surrounding graft should be opened and the kinking protector within the outflow graft removed, disconnected from the old (thrombosed or otherwise damaged) pump, and connected to the new pump. Thereafter, the polytetrafluoroethylene (Gore-Tex) graft should be closed (using suture or clips) to protect against adhesion and to facilitate any unlikely future exchange of the pump. We use the technique described for all HeartWare HVAD implantation approaches, that is, median sternotomy and left lateral or bilateral thoracotomy. To avoid twisting of the outflow graft during aortal anastomosis, the position of the black line on the outflow graft should be kept in mind. This technique has been routinely used in our center since the last 100 HVAD implantations. No evidence of increased infection has been noted. In 2 cases in which the kinking protector was covered, pump exchange was performed fast and without any complications. During heart transplantation in the described patients, reopening of the chest and separation of the heart from pericardium also were less traumatic. We thank Anne Carney of the Deutsches Herzzentrum Berlin for editing the manuscript and Dr J. Lavee for the encouragement to publish this technique.