Anesth Analg 2006;103:1412-1413
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000243330.74987.28
CARDIOVASCULAR ANESTHESIA
Placement of the TandemHeart® Percutaneous Left Ventricular Assist Device
Mias Pretorius, MBChB, MSc*,
Alexander K. Hughes, MD*,
Matthew B. Stahlman, MD ,
Pablo J. Saavedra, MD,
Robert J. Deegan, MBBCh, PhD*,
James P. Greelish, MD , and
David X. Zhao, MD
From the *Department of Anesthesiology, Department of Cardiac Surgery, Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
Address correspondence and reprint requests to Mias Pretorius, MBChB, MSc, 1235 MRB IV, 2215B Garland Ave., Vanderbilt University Medical Center, Nashville, TN 37232-0575. Address e-mail to mias.pretorius{at}vanderbilt.edu.
We report a case in which a TandemHeart (CardiacAssist, Pittsburgh, PA) percutaneous left ventricular assist device (pVAD) was placed for temporary circulatory support in a 20-yr-old female who presented with cardiogenic shock secondary to viral myocarditis. Despite inotropic support with milrinone 0.5 µg/kg/min, norepinephrine 12 µg/min, and an intraaortic balloon pump, her cardiac index remained <2.0 L/min/m2 and she developed nonoliguric acute renal failure. She was taken to a cardiac operating room with full cardiac catheterization capabilities for placement of a pVAD. She received general endotracheal anesthesia and was monitored with a pulmonary artery catheter, arterial line, and transesophageal echocardiography (TEE).
The TandemHeart System consists of a centrifugal pump, a system controller, and a cannula set (1). Femoral venous access was obtained percutaneously and a guidewire was passed into the right atrium under fluoroscopic guidance. The midesophageal (ME) bicaval view confirmed the presence of the guidewire in the right atrium. A Mullins guide catheter (Medtronic, Minneapolis, MN) was then positioned to the superior vena cava, the guidewire removed, and a transseptal needle (Cook, Bloomington, IN) loaded to a position within the catheter near the tip. Next, the fossa ovalis was identified (thinnest portion of the interatrial septum) using the ME aortic valve short axis view (40°–50°). The transseptal needle-dilator-sheath unit was manipulated under echocardiographic and fluoroscopic guidance to the region of the fossa ovalis. TEE allowed observation of "tenting" or billowing of the fossa ovalis into the left atrium (LA) followed by transseptal puncture (Fig. 1; also please see video clip available at www.anesthesia-analgesia.org). TEE visualization of the needle tip is critical to prevent puncture of the aorta or atrial wall (2). After confirming successful transseptal puncture, the Mullins tip was extended over the needle tip within the LA. With the Mullins sheath fixed, the transseptal needle was then exchanged for a guidewire, which was then advanced into the left upper pulmonary vein. This was visualized in the ME four-chamber view with the transducer rotated to 70°. The puncture hole was then dilated using a two-stage dilator. Advancement of a sheath and dilator across the septum should be accomplished over a guidewire directed to a pulmonary vein for optimal safety. The radiopaque transseptal cannula was advanced through the femoral vein across the atrial septum into the LA. The guidewire was first removed followed by removal of the obturator, once proper positioning of the cannula in the LA was verified by both fluoroscopy and TEE. TEE confirmed that all the inflow holes of the transseptal cannula were on the LA side (Fig. 2). An arterial cut-down was necessary to place the femoral cannula. The arterial and venous cannulae were then connected to the centrifugal pump. The pump pulls oxygenated blood from the LA and returns it to the systemic arterial circulation, thus initiating partial left heart bypass. pVAD flows were initiated at 3 L/min. Color Doppler TEE of the transseptal cannula demonstrated proper flow with no entrainment of blood from the right atrium. A TEE evaluation excluded pericardial tamponade.
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Figure 1. Two-dimensional midesophageal short axis view of aortic valve. Arrows indicate transseptal puncture of the atrial septum. RA indicates right atrium; LA indicates left atrium; AV indicates aortic valve.
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Figure 2. Two-dimensional midesophageal short axis view of aortic valve. Arrows indicate TandemHeart transseptal cannula in place. RA indicates right atrium; LA indicates left atrium; AV indicates aortic valve.
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Because of a diagnosis of heparin-induced thrombocytopenia, anticoagulation was provided with argatroban to maintain the activated partial thromboplastin time between 60 and 80 s. The patient's cardiac index improved to 3 L/min/m2 and the acute renal failure resolved. Five days later she underwent an orthotopic heart transplant and was discharged from hospital on postoperative day 14.
Intraoperative TEE assists in transseptal puncture, placement of the transseptal cannula, and diagnosis of potential complications associated with this procedure.
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Footnotes
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Accepted for publication August 10, 2006.
This article has supplementary material on the Web site: www.anesthesia-analgesia.org.
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REFERENCES
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- Thiele H, Lauer B, Hambrecht R, et al. Reversal of cardiogenic shock by percutaneous left atrial-to-femoral arterial bypass assistance. Circulation 2001;104:2917–22.[Abstract/Free Full Text]
- Ballal RS, Mahan EF III, Nanda NC, Dean LS. Utility of transesophageal echocardiography in interatrial septal puncture during percutaneous mitral balloon commissurotomy. Am J Cardiol 1990;66:230–2.[Web of Science][Medline]
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