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The Treatment of Rectum Cancer After HeartMate II® (Thoratec) Implantation
Non-cardiac surgery can be applied to ventricular assist device implantated patients . In these patients, hemodynamic monitoring, anticoagulation and antibiotic management is very important. 55 year old male patient with the diagnosis of dilated cardiomyopathy was admitted to our hospital with hematochezia 2 months after implantation of the Heartmate II® (Thoratec). The diagnosis was rectum carcinoma and by neoadjuvant chemotherapy we applied low anterior resection with a combined surgery . After successfully drainage of abscess formation the patient was discharged with healing.
Even though the left ventricular asist devices(LVADs) do not seems like destination therapy for terminal dilated cardiomyopathy by these paliative surgical interventions patients who implanted LVAD could be bridged for transplantation.
Keywords: LVAD, Cancer, Heartmate II, Destination Therapy
55 year old male patient 84 kg, height 172 cm with a diagnosis of dilated cardiomyopathy admitted to our hospital. When he applied, on transthoracic echocardiographic evaluation his ejection fraction (EF) was %20; mild mitral insuffenciency and advanced tricuspid insufficiency recognized. Pulmonary artery pressure (PAP) assessed as 60 mmHg and pulmonary vascular resistance (PVR) was 5.5 woods unite.
When he was on the list of elective awaiting heart transplantation, he fall into low cardiac output syndrome (LCOS). Our team decided to implant a left ventricular asist device (LVAD); and HeartMate II® was electively placed as the aim of bridging to the heart transplantation. In a LVAD, the inflow cannula is implanted to the apex of the left ventricul and the outflow cannula is implanted to the ascending aorta. At the same stage tricuspid DeVega's annuloplasty (TDVA) was performed to the patient. After 2-months of follow-up of LVAD placement, he had remarkabled improvement in his heart failure symptoms and his exercise tolerance improved. Meanwhile patient applied with rectal bleeding complaint; hematochezia was observed and rectum carcinoma was diagnosed by rectosigmoidoscopic biopsy. The grade of the tumor detected as T3N2. The team decided to start radiotherapy before surgery. Neoadjuvan radiotherapy applied by consultation of oncology department . Two weeks after therapy the patient underwent a low anterior resection operation by laparatomy and by the support of HeartMate II® without any bleeding or thromboembolic problem. The low molecular weight heparin (Enoxaparin) is used during the operation for the anticoagulation. He was started for subcutaneus enoxaparin 3 days before surgery and warfarin was stopped. Intraoperative echocardiography was available, and a cardiothoracic anesthesist who was aware of the case was ready. Rhythm of the heart, capillary wedge pressure and systemic blood pressure via radial cannulation were moniterized. The trans eusophagial echocardiography (TEE) was used for ventricular filling and four chamber visualisation. The patient arrived at the operating theatre with the LVAD nurse on the day of surgery. The patient seemed comfortable, was not dyspnoeic, and was able to complete sentences without difficulty. The LVAD was checked and the battery back-up tested to counter intraoperative power failure. Arterial pressure was 90 mm Hg systolic, 60 mm Hg diastolic with a mean arterial pressure (MAP) of 65 mm Hg and the oxygen saturation 98% on room air. He was given midazolam 2 mg for anxiolysis. An arterial line inserted before induction of anaesthesia, and central venous pressure (CVP) monitoring, even though stable laparotomy procedures do not cause remarkable revisions in the intravascular volume. Arterial cannulation was difficult as peripheral pulses were not palpable therefore Doppler guidance was required to cannulate the right radial artery. The arterial pressure recorded by invasive monitoring was 90/60 mm Hg (MAP 65 mm Hg) and heart rate was 80-87 beats for a min. The LVAD was switched on to a fixed mode and connected to the mains supply on arrival to the operating theatre. Speed of pump was run at 9400 rpm with a pulsatile index of 4.2 and a flow of 4.1 litre/min. Low anterior resection with opening a colostomy were applied to the patient by gastrointestinal surgeons and the patient remained hemodynamically stable throughout the procedure and he was then transferred to the surgical intensive unit with the LVAD on battery accompanied by the LVAD nurse. After 6 days of stay in the surgical intensive care unit, the patient was discharged to the service with instructions to continue his medications till he gets called back in for the heart transplantation. At 2nd months, febrile neutropenia was developed and followed by bleeding and purulent discharges from lower gastrointestinal system. Even though better clinical outcomes have been achieved with the newer generation continuous-flow devices, infection complications—in particular sepsis—are still a major risk for patients with continuous-flow LVAD implantation.7 White blood cells counted as 3180 x10^3 and CRP was 29.8. mg/dL fever encountered as 38.9 °C . It revealed as febril neutropenia due to chemotherapy protocol for 3 weeks and piperacylin medication started by consultation to department of enfection diseases. Abdominal computerised tomography showed an abscess formation in the operation side of the patient; and it was drained by a transrectal catheter application at follow up. Fig1.
A number of ongoing clinical trials are evaluating the efficacy of LVADs as an alternative to heart transplant ‘destination therapy’.1-6 Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart failure (REMATCH) trial has shown that an implantable LVAD prolongs and enhances the quality of life in heart failure patients.2 For the patient who has ventricular asist device, the non cardiac procedural operations may become probleamatic. Four aspects have to be considered in the management of patients with LVADs presenting for non-cardiac surgery: (a) LVAD specialists, (b) power supply and electromagnetic interference, (c) hemodynamics, and (d) anticoagulation.3 Recognition of the unique potential problems that the LVAD recipient may encounter in the perioperative period- in particular, patient positioning, device limitations, and fluid and inotropic management-will ensure an optimal surgical outcome for LVAD recipients undergoing noncardiac surgery.4
LVADs have to be connected to the main supply when the patient comes the operating theatre. The device is prone to alteration by electromagnetic interference such as electrocautery or a defibrillator. Bipolar cautery should be used when possible and the grounding pad placed to facilitate current dispersion away from the device.4 Routine Intravenous and inhalational anesthetic materials are well tolerated in LVAD implanted patients. The fluid, inotropic, and vasopressor requirements do not appear to be significantly different than those required in other patients undergoing similar procedures. Echocardiography should be used especially for the control of preload and fluid management. Therefore mean arterial pressure, central venouse pressure and capillary wedge pressure are always monitorized and the all cardiac parameters were controlled with TEE. HeartMate II® LVAD is a device that has a low incidence for thromboembolism.5 Warfarine was stopped while abdominal operation and the treatment was continued just by DMAH (Enoxaparin).
As a conclusion the heart failure patients may achieve to survive a near normal life in their own habits by impoartant contribution of ventricular asist devices to their functional capacity and execise tolarence. That means operating teams will come upon ever so often with LVAD implanted patients in the operating room for many surgical indications in the near future. For the safe and successfull results we need impressive team work.