Canadian Journal of Cardiology 33 (2017) 950.e11e950.e13 www.onlinecjc.ca
Case Report
Extended Bridge to Heart and Lung Transplantation Using Pumpless Extracorporeal Lung Assist Vishnu Vasanthan, BMSc,a,c Manish Garg, MCh,a,c Michiko Maruyama, MD,a,c Evangelos Michelakis, MD,b,c Darren H. Freed, MD, PhD,a,c,d,e and Jayan Nagendran, MD, PhDa,c,d,e a b
Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
Department of Medicine, University of Alberta, Edmonton, Alberta, Canada c
Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada d
e
Alberta Transplant Institute, Edmonton, Alberta, Canada
Canadian National Transplant Research Program, Edmonton, Alberta, Canada
ABSTRACT
RESUM E
In end-stage idiopathic pulmonary artery hypertension (iPAH), centrally cannulated Novalung (Novalung GmbH, Hechingen, Germany) pumpless extracorporeal lung assist (pECLA) decompresses the pulmonary artery for bridge to transplantation. We report placing a 45-year-old man with end-stage iPAH and right heart failure on centrally cannulated pECLA for 82 days as a bridge to heart and double-lung transplantation (HLTx). To our knowledge, this is the longest reported bridge to transplantation in Canada and the first successful bridge to HLTx. We demonstrate how pECLA permits mobility, facilitating physiotherapy to ensure fitness for transplantation. Considering the irreversible right heart failure, HLTx remains suitable in iPAH.
rielle pulmonaire idiopathique (HTAPi) Dans les cas d’hypertension arte terminale, un poumon artificiel sans pompe (PASP) à voie centrale Novalung (Novalung GmbH, Hechingen, Germany) permet de compresser l’artère pulmonaire dans l’attente d’une greffe. Nous de signalons le cas d’un homme de 45 ans atteint d’HTAPi terminale et te d’insuffisance cardiaque droite chez qui un PASP à voie centrale a e puis utilise durant 82 jours dans l’attente d’une greffe cœurimplante riode d’attente avant poumons (GCP). À notre connaissance, cette pe e au Canada et la première une greffe est la plus longue jamais signale e à une GCP. Nous de montrons comment le PASP assure ayant mene du patient et facilite par le fait même la physiothe rapie la mobilite paratoire à une greffe. En pre sence d’insuffisance cardiaque droite pre versible, la GCP demeure indique e en cas d’HTAPi. irre
In end-stage idiopathic pulmonary artery hypertension (iPAH), a centrally cannulated Novalung (Novalung GmbH, Hechingen, Germany) pumpless extracorporeal lung assist (pECLA) decompresses the pulmonary artery (PA) for bridge to transplantation.1 We report placing a 45-year-old man with end-stage iPAH and right heart failure on centrally cannulated pECLA for 82 days as a bridge to heart and double-lung transplantation (HLTx). The Novalung enabled our cachectic patient to participate in physiotherapy and nutritional support to ensure fitness for transplantation.
Case Presentation A 45-year-old man (Table 1) who had had iPAH for 12 years presented with respiratory and right heart failure. Echocardiography (Table 1) revealed severe right atrial and right ventricular (RV) dilatation and high RV pressures. Computed tomography showed RV dilatation causing left ventricular compression (Fig. 1A). After pharmacotherapy failed, lung transplantation (LTx) was indicated. Because no organs were available, a pECLA device was inserted (Fig. 1B) as a bridge to transplantation.1 Cannulation was performed through the PA (36F straight, Medtronic 66263; inflow) and left atrium (32F angled, Medtronic 67532; outflow). PA and central venous pressures decreased, and venous oxygen saturation increased (Table 1). Device flows were 3.0-3.5 L/min. The patient underwent anticoagulation with warfarin, which was discontinued after 63 days because of recurrent epistaxis and gastrointestinal bleeding. Given the suspicion of heparin-induced thrombocytopenia, he was switched to bivalirudin. Acetylsalicylic acid
Received for publication January 27, 2017. Accepted March 13, 2017. Corresponding author: Dr Jayan Nagendran, Division of Cardiac Surgery, Department of Surgery, University of Alberta and Mazankowski Alberta Heart Institute, 4-108A Li Ka Shing Health Research Centre, Edmonton, Alberta, Canada T6G 2E1. Tel.: þ1-780-492-7605; fax: þ1-780-492-6037. E-mail:
[email protected] See page 950.e13 for disclosure information.
http://dx.doi.org/10.1016/j.cjca.2017.03.014 0828-282X/Ó 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
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Canadian Journal of Cardiology Volume 33 2017
Table 1. Surgical data Variable
Value
Hospital stay (d) pECLA duration (d) Central venous pressure (mm Hg) Before Novalung insertion After Novalung insertion Pulmonary artery pressure (mm Hg) Before Novalung insertion After Novalung insertion Hospital stay after HLTx (d) Total ischemic time (min) Primary graft dysfunction scores 0h 24 h 48 h 72 h Pulmonary function after transplantation (% predicted) 1 mo
122 82
4 mo 8 mo Echocardiography Initial presentation RV basal diameter (cm) RV systolic pressure (mm Start of pECLA RV basal diameter (cm) RV systolic pressure (mm End of pECLA RV basal diameter (cm) RV systolic pressure (mm 8 mo after HLTx RV basal diameter (cm) RV systolic pressure (mm
22 16 72/41 45/29 32 143 3 2 2 1 FEV1 ¼ 35 FVC ¼ 35 FEV1 ¼ 67 FVC ¼ 75 FEV1 ¼ 84 FVC ¼ 80
Hg)
5.8 74
Hg)
4.8 40-50
Hg)
5.7 30-40
Hg)
3.1 16.9
was given for antiplatelet therapy. Hemodynamics were initially managed with dobutamine, milrinone, epinephrine, and norepinephrine, which were weaned over 3-4 weeks, although the patient had intermittent mild hypotension and as such was eventually given midodrine during the 5 weeks before transplantation. Because of initial cachexia (body mass index < 17), the patient was deemed unfit for surgery and was deactivated from the transplantation waiting list. Fortunately, additional mobility permitted by pECLA facilitated extensive physiotherapy and nutritional support, enabling improvements in strength, ambulation, and weight (6.8 kg). His daily routine included increasing amounts of physiotherapy to improve his strength for ambulating around the unit. Feeding was initially with total parenteral nutrition. He progressed to low-calorie nasogastric tube feeding and then to calorie-dense feeding. Although he had difficulty swallowing, he could ingest thick fluids orally by the time of transplantation. Continuous renal replacement was initiated to manage acute renal injury, which was changed to nocturnal prolonged intermittent renal replacement to enhance daytime mobility. The patient progressed to intermittent hemodialysis and was eventually weaned. Until the final week of bridging, urination was managed by a Foley catheter to monitor output. A rectal tube was placed for the first 24 days and removed once bowel movements became more formed and ambulation improved. After 49 days of rehabilitation, he was reactivated for transplantation.
Figure 1. (A) Chest computed tomographic scan of patient with idiopathic pulmonary artery hypertension. High pulmonary artery and right ventricular pressure/dilatation caused left ventricular compression. (B) Central cannulation strategy of Novalung pumpless extracorporeal lung assist. Cannulating the pulmonary artery and left atrium serves as inflow and outflow, respectively. CS, coronary sinus; LV, left ventricle; RA, right atrium; RV, right ventricle.
Despite long-term afterload reduction on pECLA, poor RV contractility and very severe RV dilatation (short axis, 53 mm; long axis, 97 mm) persisted after 7 weeks of pECLA. These clinical findings suggested poor RV function after
Vasanthan et al. Central Cannulated NovalungdBridge to Transplantation
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LTx. Thus, the patient was listed for HLTx. After 82 days of bridging to transplantation, HLTx was performed. Specimens of the native right ventricle showed extensive endomyocardial fibrosis, supporting the clinical decision of HLTx over double LTx because the right ventricle was not likely to recover. After 82 days of bridging to transplantation, HLTx was performed. The patient was discharged after an uncomplicated 1-month recovery. Pulmonary and RV function improved (Table 1). He is alive 1 year after transplantation.
Conclusions In end-stage iPAH, bridging to transplantation through centrally cannulated Novalung pECLA acts as a platform for extensive rehabilitation to ensure fitness for surgery. Although less prevalent than LTx, HLTx remains suitable for iPAH patients with irreversible right heart failure.
Discussion Our experience showcases centrally cannulated pECLA as a midterm bridge to transplantation with advantages over venovenous extracorporeal membrane oxygenation (VVECMO).2 VV-ECMO allows mobility for physiotherapy but cannot alleviate RV failure.3 Given the cachexia and cor pulmonale, Novalung pECLA facilitated intensive rehabilitation to enable fitness for HLTx. Furthermore, because the determining indication is pulmonary vascular resistance, it can be adapted for secondary PAH, including idiopathic pulmonary fibrosis, cystic fibrosis, and emphysema. With our previous Novalung cases, patients with PAH received LTx. However, this patient’s severe unrecoverable RV failure indicated an additional heart transplantation. Therefore, HLTx, although less prevalent,4 remains suitable for iPAH with irreversible RV failure. Because transplantation is the definitive cure for end-stage pulmonary disease,5 rising waiting list mortality causes a growing need for bridging to transplantation. The centrally cannulated Novalung provides the opportunity for preoperative rehabilitation and improved nutrition. Without a bridging strategy conducive to physiotherapy and supportive treatment, this patient was unlikely to survive transplantation at the time of presentation in extremis.
Disclosures The authors have no conflicts of interest to disclose.
Funding Sources Supported by the University Hospital Foundation.
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