Placement of a Large Transseptal Cannula through an Inferior
Vena Cava Filter for TandemHeart Percutaneous Left Ventricular
As
The TandemHeart left ventricular assist device (LVAD, CardiacAssist, Inc., Pittsburgh, Pennsylvania) is a percutaneous left atrial (LA)-to-femoral artery bypass system that can be implanted relatively quickly and provides up to 5 L/minute of active hemodynamic support.1 Its use requires insertion of a 21 Fr LA cannula for inflow, and a 15 Fr or 17 Fr femoral artery cannula for outflow, with the two connected by a continuous flow centrifugal pump.
The need to cross the atrial septum invariably mandates venous access from the femoral vein. Although the LA can be accessed from the right internal jugular (RIJ) vein, the TandemHeart LA cannula is not designed for insertion from this route.
Previously, the presence of an inferior vena cava (IVC) filter was considered a relative contraindication to right-heart catheterization from the femoral vein.2–4 More recently, it has been demonstrated that right-heart catheterization, and even patent foramen ovale and atrial septal defect closures and balloon mitral valvuloplasty, could be safely performed through IVC filters using sheath sizes up to 16 Fr.5–9 We report a case of successful TandemHeart implantation for cardiogenic shock due to critical aortic stenosis (AS) in a patient with an IVC filter, using a 21 Fr transseptal cannula.
Case Report. An 83-year-old male was admitted with increasing shortness of breath due to congestive heart failure. His past medical history included coronary artery bypass graft surgery 10 years ago, type 2 diabetes, and atrial fibrillation on oral anticoagulants.
He was in a pre-shock state with a systolic blood pressure of between 80–90 mmHg. Echocardiography revealed critical AS with an aortic valve area of 0.6 cm2 and a left ventricular ejection fraction (LVEF) of only 15%. Aggressive medical therapy was instituted. During that time, he was found to have bilateral deep venous thromboses despite oral anticoagulants. A Bard G2 Filter System (Bard Peripheral Vascular, Inc., Tempe, Arizona) IVC filter was placed as a prophylaxis against pulmonary embolism. His condition did not improve, however, and he remained in the pre-shock state. The decision was made to implant a percutaneous ventricular assist device (pVAD), as he was deemed too ill to undergo surgical VAD implantation.
The patient was brought to the catheterization laboratory and a right-heart study was performed using a 7 Fr Swan Ganz catheter via the left femoral vein. The Swan Ganz catheter was passed under fluoroscopic guidance across the IVC filter without difficulty. There was severe pulmonary hypertension with a significantly elevated pulmonary capillary wedge pressure (PCWP) of 40 mmHg, consistent with severe heart failure. The Swan Ganz catheter was left in situ. An abdominal aortogram with distal runoff was performed with a pigtail from the left common femoral artery (LCFA), revealing anatomy suitable for placement of the arterial cannula. A second venous access was obtained via the right femoral vein. A 0.032 inch wire was first advanced under fluoroscopic guidance across the IVC filter and then followed by an 8 Fr Mullins sheath. Transseptal puncture was then performed using standard techniques. Atrial septal dilatation was performed with a 14 Fr dilator (Figure 1). The 21 Fr TandemHeart transseptal cannula was then advanced across the IVC filter under direct visualization to the LA (Figures 2–4). A 17 Fr arterial cannula was then placed via the LCFA into the left iliac artery. The cannulae were connected, and the pump was started, with PCWP decreasing immediately after initiation of the TandemHeart to 25 mmHg and resultant significant clinical improvement of his symptoms.
Balloon aortic valvuloplasty was performed the next day using a 22 x 60 mm Z-Med balloon, resulting in a reduction of the mean aortic pressure gradient from 30 mmHg to 18 mmHg. Coronary angiography prior to the valvuloplasty revealed a patent left internal mammary graft to the left anterior descending artery and a patent saphenous vein graft to the obtuse marginal artery, with mild disease of the right coronary artery. The patient’s condition improved and he underwent surgical bioprosthetic aortic valve replacement 5 days after the index procedure. The TandemHeart device was surgically explanted 2 days later, with insertion of an intra-aortic balloon pump. The patient had a prolonged but complete recovery, with implantation of a biventricular implantable cardioverter-defibrillator 3 weeks after the index procedure. He was discharged home 1 month after the index procedure.
Discussion. This case demonstrates that a 21 Fr transseptal cannula of the TandemHeart device can be safely placed across the IVC filter into the LA.
The TandemHeart pVAD was instrumental in stabilizing this extremely high-risk patient who had low blood pressure, severely depressed LVEF and critical AS, making it possible for him to undergo balloon aortic valvuloplasty. This served as a bridge to his surgical aortic valve replacement and eventual recovery. The Tandem Heart pVAD is a LA-to-femoral artery bypass system that includes a transseptal cannula, an arterial cannula and a centrifugal pump. The transseptal cannula aspirates oxygenated blood from the LA. Blood is then pumped into the femoral artery through the arterial cannula. The continuousflow centrifugal pump can provide flows of up to 5.0 L/minute at a maximum speed of 7,500 rpm. This pVAD has been shown in previous studies to provide beneficial hemodynamic effects almost immediately, with increases in mean arterial pressure and cardiac index, and a decrease in wedge pressure, although no mortality benefit could be demonstrated due to small patient numbers.1,10,11 It has been used in cardiogenic shock due to a variety of clinical conditions such as myocardial infarction, decompensated chronic heart failure, postpericardiotomy shock, acute valve failure and myocarditis, and was most useful as a bridge to definitive therapy.10–13
Previous reports have shown the feasibility of transcatheter interventions with large sheaths through an existing IVC filter.6–9 The largest sheath size reported was 16 Fr. This report now demonstrates the feasibility and safety of crossing an IVC filter with a 21 Fr sheath, if done carefully under fluoroscopic guidance.
Although previous reports recommend IVC angiography prior to any catheter manipulation across the IVC filter, this was felt to be unnecessary in our patient, as the IVC filter had just been placed several days earlier with a low likelihood of large amounts of trapped thrombus. Also, biplane fluoroscopic guidance was not necessary, as suggested in previous reports, since the pVAD cannula was adequately visualized when crossing the IVC filter.
Conclusion. Transcatheter interventions through an IVC filter have been reported with large sheaths up to 16 Fr in size. These were mainly for percutaneous patent foramen ovale/atrial septal defect closures and balloon mitral valvuloplasty. We now report a case of TandemHeart pVAD implantation across an IVC filter with a 21 Fr size transseptal cannula. This enabled stabilization of the patient, with subsequent balloon aortic valvuloplasty followed by definitive surgical aortic valve replacement and a successful hospital outcome. Patients with severely compromised cardiac function and an existing IVC filter can safely undergo implantation of the TandemHeart pVAD, provided careful techniques and fluoroscopic guidance are used, and should not be denied this device for fear of dislodging the filter. Dislodging thrombus trapped by the IVC filter remains a potential risk that nonetheless may be worthwhile in patients requiring the life-saving support of a pVAD.
References
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