Implantation of Left Ventricular Assist Device in the setting of heavily calcified left ventricular apex using an apex preserving technique

Abstract

A heavily calcified ventricular apex represents a challenging, rare and unique situation in LVAD implantation. A 44-year-old male was admitted with myocardial infarction. Left heart catheterization was complicated by episodes of ventricular fibrillation. After an acute stabilization with veno-arterial extracorporeal membrane oxygenation (VA-ECMO), an LVAD implantation was approved. Pre-operative work-up had shown a heavily calcified ventricular apex and an intraventricular thrombus, which was confirmed intraoperatively. To retain a viable ventricular geometry, the decision was made to preserve the calcified apex rather than to excise the entire calcified left ventricular aneurysm. Sutures for the inlet cannula were placed around the calcific apex (Apex Preserving) away from the core site, parachuting the inflow sewing ring into an intramyocardial position (Telescope) and assuring hemostasis by placing a felt strip on the epicardial tissue in a purse string fashion (Cerclage). The HeartMate II LVAD inflow cannula was secured into the sawing ring, and the rest of the procedure was conducted in the standardized fashion. The patient was discharged into a rehabilitation center eight weeks after LVAD implantation. Thus, if the calcific area is maintained by coring just the inflow site, the spherical shape of the ventricle is maintained to all for better positioning of the inlet cannula. The second suture line enhances hemostasis around the inflow insertion site and stays away from the calcium, which sits in a deeper layer. This procedure, the apex preserving cerclage technique (APCT), does not increase surgical time and reinforces the tissue around the inlet site.