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LETTERS TO THE EDITOR
Conflict of Interest: The authors declare that they
have no conflict of interest in this manuscript.
*Massimiliano Polastri and †Antonio Loforte
*Department of Physical Medicine and
Rehabilitation, S. Orsola-Malpighi Hospital,
Bologna and †Department of Cardiac Surgery
and Transplantation, University of Bologna,
S. Orsola-Malpighi Hospital, Bologna, Italy
E-mail: antonioloforte@yahoo.it
REFERENCES
1. Kirklin JK, Naftel DC, Pagani FD, et al. Sixth INTERMACS
annual report: a 10,000-patient database. J Heart Lung Trans-
plant 2014;33:555–64.
2. Potapov EV, Loforte A, Weng Y, et al. Experience with over
1000 implanted ventricular assist devices. J Card Surg 2008;23:
185–94.
3. Yoon JY, Lim WT, Oh JS. Influence of the strap-length on the
trunk motion and gait symmetry in Korean women carrying a
single-strap bag. J Back Musculoskelet Rehabil 2012;25:269–74.
4. Krabatsch T, Potapov E, Stepanenko A, et al. Biventricular
circulatory support with two miniaturized implantable assist
devices. Circulation 2011;124:S179–86.
Left Ventricular Assist Device
Implantation With Dor Procedure via
Bilateral Limited Thoracotomy
To the Editor,
Left ventricular assist device (LVAD) implanta-
tion in patients with a Dor procedure is uncommon
and surgically challenging; only a few cases, done via
median sternotomy, are reported (1,2). We present
our technique of Dor procedure with LVAD implan-
tation via bilateral limited thoracotomy.
CASE PRESENTATION
A 57-year-old male patient on polyinotropic
support and mechanical ventilation following isch-
emic cardiac arrest and cardiogenic shock was
referred for evaluation and further therapy. An
intraaortic balloon pump (IABP) was inserted on
admission. Echocardiography revealed a dilated,
“fluttering” left ventricle (LV) (LVEF <10%), and
revascularization was not indicated. Appropriate
neurological status was confirmed by withholding
sedation, but the patient was hemodynamically
unstable with continuing deterioration, and LVAD
doi:10.1111/aor.12429
641
implantation (HeartWare, Inc., Framingham, MA,
USA) as bridge-to-heart transplantation was consid-
ered.
SURGICAL PROCEDURE
At our center, LVAD implantation is routinely
done via bilateral limited anterolateral thoracotomy
using <10 cm incisions, through the left fifth and
right fourth intercostal spaces (3). Cardiopulmonary
bypass was instituted via percutaneous femoral
access. The LV was exposed and found to have a thin,
aneurysmal anterior wall. The LVAD ring was posi-
tioned appropriately, secured with interrupted
pledgetted 2-0 Ethibond sutures, and an LV vent
inserted through it. The LV aneurysm was opened
parallel to the left anterior descending artery and
examined for thrombi (Fig. 1A). An appropriate
boundary for endoaneurysmorrhaphy was defined
between nonviable and healthy myocardium, demar-
cated by longitudinal Teflon strips (Bard PTFE Felt,
Bard Peripheral Vascular, Inc., Tempe, AZ, USA)
(Fig. 1B). A 2 mm-thick GoreTex endoventricular
patch (W. L. Gore & Associates (UK) Ltd, Dundee,
Scotland) was used to restore the LV cavity (Fig. 1C)
as described by Dor (4). The LVAD inflow-cannula
was inserted through the patch (Fig. 1D). The left
ventriculotomy was closed over the patch by
oversewing and approximating the edges of the origi-
nal LV aneurysm (Fig. 1E). The outflow graft was
tunneled retrosternally to the right and anastomosed
to the ascending aorta (3). Stable LVAD flows >5 L/
min were achieved. The pericardium was closed with
a 1 mm GoreTex patch (Fig. 1F) to avoid adhesions
at the time of transplantation.
The IABP was weaned off after 24 h. The patient
was extubated after 48 h of hemodynamic stability,
and is currently recovering on the ward.
DISCUSSION
This report describes the Dor procedure with simul-
taneous LVAD implantation without sternotomy.
Apical ventriculotomy, aneurysm resection, and
patch placement for the Dor procedure make apical
cannulation for LVAD insertion difficult (1). Never-
theless, in a thinned and aneurysmal LV wall, the
Dor procedure may be necessary to provide a stable
cannulation site for securely retaining the LVAD
placement and orientation. The LVAD inflow
cannula can be directly anastomosed to the patch if
the remaining LV cavity is large enough to prevent
suctioning. Avoiding median sternotomy may be
advantageous, especially in patients bridged to trans-
plantation, as redo-sternotomy and adhesiolysis at
Artif Organs, Vol. 39, No. 7, 2015
642 LETTERS TO THE EDITOR
A B C
D E F reconstruction. (D) Positioning of LVAD
the time of transplant may increase “out-of-body”
time for the donor organ and/or engender avoidable
complications (3), especially as the LVAD-outflow
graft may lie retrosternally and be a potential source
of adhesions. While longer-term outcomes remain
to be evaluated, we believe our sternal-sparing
approach is safe and feasible for LVAD insertion
with the Dor procedure, especially as bridge to trans-
plantation.
Author contributions: NPP: Concept, drafting,
data collection, digital artwork; AFP: critical revi-
sion; ARS: final approval.
Nikhil Prakash Patil, Aron Frederick Popov,
and André Rüdiger Simon
Department of Cardiothoracic Transplantation &
Mechanical Circulatory Support, Harefield Hospital
Royal Brompton & Harefield NHS Foundation
Trust
London, UK
E-mail: n.patil@rbht.nhs.uk
Artif Organs, Vol. 39, No. 7, 2015
FIG. 1. Surgical LV reconstruction and
assist device implantation. (A) LVAD ring
implanted, LV aneurysm opened longi-
tudinally. (B) Teflon strips demarcating
boundary of aneurysm. (C) LV patch
inflow cannula through LV patch. (E) Left
ventriculotomy closed over LV patch. (F)
Pericardial patch closure to minimize
adhesions.
REFERENCES
1. Osaki S, Edwards NM, Kohmoto T. Strategies for left ventricu-
lar assist device insertion after the Dor procedure. J Heart Lung
Transplant 2009;28:520–2.
2. Garbade J, Bittner HB, Barten MJ, et al. Combined surgical
left ventricular reconstruction and left ventricular assist device
implantation for destination therapy in end-stage heart failure.
Circ Heart Fail 2011;4:e14–5.
3. Popov AF, Hosseini MT, Zych B, Simon AR, Bahrami T.
HeartWare left ventricular assist device implantation through
bilateral anterior thoracotomy. Ann Thorac Surg 2012;93:
674–6.
4. Dor V, Di Donato M, Sabatier M, Montiglio F, Civaia F. Left
ventricular reconstruction by endoventricular circular patch
plasty repair: a 17-year experience. Semin Thorac Cardiovasc
Surg 2001;13:435–47.