ARTICLE IN PRESS

www.icvts.org
doi:10.1510/icvts.2010.252908
Interactive CardioVascular and Thoracic Surgery 12 (2011) 110111
2011 Published by European Association for Cardio-Thoracic Surgery
Work in progress report - Assisted circulation
Implantation technique of the CentriMag biventricular assist device
allowing ambulatory rehabilitation
Hiroo Takayama , Jonathan M. Chen , Ulrich P. Jorde , Yoshifumi Naka *
a b c a,
Division of Cardiothoracic Surgery, Columbia University Medical Center, Milstein Hospital Building 7-435, 177 Fort Washington Avenue,
a
New York, NY 10032, USA
Division of Pediatric Cardiac Surgery, Weill Cornell University Medical Center, New York, NY, USA
b
Division of Cardiology, Columbia University Medical Center, New York, NY, USA
c
Received 26 August 2010; received in revised form 13 October 2010; accepted 14 October 2010
Abstract
Non-implantable ventricular assist device plays a major role in emergent or urgent situation where a patient has acutely decompensating
hemodynamics. One of its major disadvantages is that the patient needs to be bed-bound after insertion. We have developed a surgical
technique that allows ambulatory management of the patients who received non-implantable device with CentriMag.
2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Keywords: Ventricular assist device; CentriMag; Rehabilitation
1. Introduction
Implantable left ventricular assist devices (LVADs) are
increasingly used for end-stage heart failure patients with
broadening indications due to the rapid advancement in
device technology
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1, 2
x
. These devices are not ideal for a
patient who is acutely decompensating from cardiogenic
shock. Rather, short-term support devices, which allow
biventricular, easier and quicker insertion, are the device
of choice. The latter devices are, however, not designed to
be used in an ambulatory setting, and thus the supported
patients are usually bed-bound. Among short-term support
devices, CentriMag technology is becoming popular due to
its ease in insertion and maintenance as well as conceptual
advantage of a bearingless pump
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. We have inserted
CentriMag devices in over 70 patients with satisfactory
outcomes, and the CentriMag biventricular assist device
(BiVAD) is currently our first choice device in acute cardio-
genic shock. Some of the patients were supported for a
relatively long time, during which they participated in
ambulatory rehabilitation once the general condition had
stabilized (Fig. 1). Here we describe our insertion tech-
nique that allows this ambulatory management.
2. Operative technique
The right ventricular assist device (RVAD) is usually estab-
lished with the right atrium as the inflow and the main
pulmonary artery as the outflow. The outflow of the LVAD
is the ascending aorta except in unusual cases where the
*Corresponding author. Tel.: q1-212-305-6380; fax: q1-212-342-3520.
E-mail address: yn33@columbia.edu (Y. Naka).
descending aorta or a more peripheral branch may be
considered. The inflow of the LVAD is chosen based on the
patients condition. The inflow cannula is inserted into the
left ventricle when myocardial recovery is a possibility.
This is done either through left ventricular apical cannula-
tion or by advancing the left atrial cannula into the left
ventricle through the mitral valve. Otherwise, the left
atrium is cannulated. Although the apical cannulation pro-
vides most reliable decompression of the left ventricle, it
requires mobilization of the left ventricle, which compro-
mises the hemodynamics. Our most common choices of
cannulas are as follow: 2024 Fr elongated on-piece arterial
cannula (Medtronic, Inc, MN, USA) for the pulmonary artery,
31 Fr DLP right angle metal tip venous cannula (Medtronic,
Inc, MN, USA) for the right atrium or right ventricle, 7
8 mm Sarns soft flow aortic cannula (Terumo Corp., Tokyo,
Japan), 31 Fr right-angle metal tip venous cannula for the
left atrium, and 3640 Fr DLP malleable single stage venous
cannula (Medtronic, Inc, MN, USA) for the left ventricle
(either through the left atrium or the left ventricular apex).
The procedure is performed without cardiopulmonary
bypass support whenever feasible.
After a median sternotomy, double purse-string sutures
with 2-0 or 3-0 polypropylene buttressed with bovine peri-
cardial pledgets are placed at the cannulation sites and
passed through DLP tourniquets (Medtronic, Inc, MN, USA).
The cannulae are introduced into the pericardial cavity
through separate stab wounds at the upper abdomen.
Cannulation is performed and the cannulae are secured to
the tourniquets with 0 silk ties. These tourniquets are
folded and tied with another 0 silk tie on to the cannulae
at their entry point to the posterior aspect of the rectus
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Fig. 1. A patient ambulating with CentriMag BiVAD. BiVAD, biventricular assist
device.
Fig. 2. (a) Cannulation for CentriMag BiVAD. The arrow indicates the anchor
tie (Fleur-de-Lis tie) on the pulmonary artery cannula at the fascia of the
rectus abdominis muscle. The pulmonary artery cannula is pushed in to show
the tie. (b) The pulmonary artery cannula is pulled back to its secure posi-
tion. The Fleur-de-Lis tie prevents further migration of the cannula. BiVAD,
biventricular assist device.
abdominis muscle fascia (Fig. 2). This looks like a Fleur-
de-Lis and works as an anchor, and further secures and
immobilizes the cannulae. When there is enough length,
the tourniquets are folded back again for better anchoring.
Securing the folded tourniquets at an appropriate point
onto the cannulae is the key of this technique. This point
is determined at the level of the posterior rectus fascia to
leave appropriate length of the cannulae in the pericardial
space. This immobilizes the cannulae and prevents migra-
tion during aggressive physical activity with rehabilitation.
Attention is paid to ensure the folded tourniquets are
working as secured anchors by forcefully pulling back the
cannulae. Each cannula is sutured onto the skin at three
points, connected to the BiVAD circuit, and the BiVAD is
actuated. Drains are placed and the sternotomy wound is
closed in the usual fashion.
Postoperatively, an abdominal binder is used at the upper
abdomen. The patients are allowed to be out of the bed
as soon as they are extubated, and early rehabilitation is
initiated by the physical therapists. Further rehabilitation
is facilitated to walk as the patients tolerate either in the
intensive care unit or in the general floor. The longest
support with the CentriMag was 144 days. From January
2007 until August 2009, 63 patients underwent surgical
CentriMag ventricular assist device (VAD) placement for
cardiac support. The majority of those who recovered from
acute illness were mobilized out of the bed, and 14 patients
were able to ambulate and participated in rehabilitation.
There was no adverse event associated with physical
activity.
3. Discussion
Although CentriMag VADs are designed and approved only
for short-term support, our insertion technique allows long-
er-term use, when needed, without forced bed rest. Ambu-
latory rehabilitation has many advantages and prepares the
patients for the next stage of the treatment, such as
implantable long-term VADs or heart transplantation. A
highly redundant safety system is achieved by maximizing
the immobilization of the cannulae through several stages;
1) securing the cannulae to the tourniquets, 2) folding the
tourniquets at the fascia level as an anchor, 3) multiple
secure sutures on the skin, and 4) abdominal binder. After
the early postoperative period, adhesion is formed around
the cannula inside of the pericardium, and this eventually
further secures the cannulae.
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