Reardon M J, Conklin L D, Letsou G V, Safi H J, Espada R, Baldwin J C
Department of Surgery, Baylor College of Medicine, Methodist Hospital, Houston, Texas, USA.
J Cardiovasc Surg (Torino). 1999 Oct;40(5):627-31.
Despite many technological advances in cardiovascular surgery, some patients still experience postcardiotomy left ventricular (LV) failure that is refractory to both inotropic support and intra-aortic balloon pump (IABP) placement. The primary author (MJR) recently changed from inflow cannulation at the right superior pulmonary vein/left atrial junction to inflow cannulation at the dome of the left atrium. The purpose of this study was to compare data collected during placement of a left ventricular assist device (LVAD) at the junction of the right superior pulmonary vein with positioning the device in the dome of the left atrium. Experimental design, setting, and participants: the medical records of all patients undergoing cardiac surgery by one author (MJR) between 1994 and 1997 were retrospectively reviewed, and 4 patients requiring LVAD placement for short term postcardiotomy support were identified. Each patient's chart was reviewed for duration of LVAD support, average LVAD blood flows, pulmonary capillary wedge pressures (PCWP), preoperative characteristics, postoperative complications, and final outcome for the patients.
Accessing the left atrium through the dome resulted in excellent blood flow through the LVAD and allowed for good LV decompression. Hemostasis remained the most common complication regardless of the technique employed; however, the enhanced visibility provided by accessing the left atrium via the dome made repairs less technically difficult. Three patients (75%) were able to be weaned from the LVAD and were discharged from the hospital to home. Two of these patients were cannulated via the left atrial dome making removal of the LVAD easier, thus exposing the patients to less additional operative time. One patient could not be weaned from LVAD support secondary to development of right ventricular failure requiring RVAD insertion and subsequent development of multiple organ failure syndrome.
Patients requiring LV assistance following cardiopulmonary bypass surgery traditionally have high levels of morbidity and mortality. In spite of the complications associated with the placement of an assist device, we remain encouraged by the excellent LV decompression and systemic flows we achieved following implantation of the LVAD through the dome of the left atrium. The superior ease of implantation and decannulation provided better operative care and postoperative management for our patients.
尽管心血管外科手术取得了诸多技术进步，但仍有部分患者在心脏切开术后出现左心室（LV）衰竭，对强心支持和主动脉内球囊反搏（IABP）置入均无效。第一作者（MJR）最近将流入插管部位从右上肺静脉/左心房交界处改为左心房顶部。本研究的目的是比较在右上肺静脉交界处放置左心室辅助装置（LVAD）与将该装置置于左心房顶部时收集的数据。实验设计、设置和参与者：回顾性分析了1994年至1997年间由一位作者（MJR）实施心脏手术的所有患者的病历，确定了4例需要LVAD进行心脏切开术后短期支持的患者。查阅了每位患者的病历，了解LVAD支持的持续时间、LVAD平均血流量、肺毛细血管楔压（PCWP）、术前特征、术后并发症及患者的最终结局。
通过左心房顶部进入可使LVAD有良好的血流，并能实现良好的左心室减压。无论采用何种技术，止血仍是最常见的并发症；然而，通过左心房顶部进入所提供的更好视野使修复在技术上难度降低。3例患者（75%）能够撤离LVAD并出院回家。其中2例患者通过左心房顶部插管，使LVAD的移除更容易，从而减少了患者的额外手术时间。1例患者因发生右心室衰竭需要置入右心室辅助装置（RVAD），随后出现多器官功能衰竭综合征，无法撤离LVAD支持。
传统上，体外循环心脏手术后需要左心室辅助的患者发病率和死亡率较高。尽管辅助装置置入存在相关并发症，但通过左心房顶部植入LVAD后实现的良好左心室减压和全身血流仍让我们备受鼓舞。植入和拔管的更高便利性为我们的患者提供了更好的手术护理和术后管理。
