Left ventricular assist device support

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Inability to discontinue cardiopulmonary bypass has become an infrequent occurrence because of improved intraoperative myocardial protection with cardioplegia and the use of cardiotonics, peripheral dilators, and intraaortic balloon pumping (IABP). For the patient who cannot be removed from bypass despite these aids, the left ventricular assist device (LVAD) is the last resort. We report the successful use of the LVAD in a patient who could not be weaned from cardiopulmonary bypass after revascularization surgery despite all other modes of therapy.

Case report

A 68-year-old white man with NYHA class IV angina and a prior myocardial infarction was found at cardiac catheterization to have total obstruction of the right coronary artery, 95% left main trunk obstruction, total occlusion of the anterior descending coronary artery, and 90% stenosis of the circumflex. The ventricular function was severely and diffusely impaired with an end-diastolic pressure of 36 mm Hg and an ejection fraction of 30%. On the morning of surgery, immediately before the induction of anesthesia, the patient had chest pain with transient electrocardiographic changes. Anesthesia was induced and he was rapidly placed on cardiopulmonary bypass. Surgery was performed; mild systemic hypothermia (32 C), topical hypothermia, and cardioplegia were used. The anterior descending and distal right coronary arteries were totally occluded and ungraftable. The diagonal branch, running parallel to the anterior descending artery, was 1.5 mm in diameter and of good quality. The lateral and posterolateral circumflex arteries were about 2.0 mm in diameter and of good quality. Aortocoronary saphenous vein bypass grafts were . . .



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