A 60-year-old male patient (weight 60 kg, height 1.70 m, body surface area 1.72 m²) was admitted with a 4-year history of chest tightness and shortness of breath, which had aggravated for 1 month. Four years ago, the patient presented with chest tightness, palpitations, and shortness of breath, which were relieved by rest. The patient did not undergo further diagnostic evaluation or treatment at that time and continued to experience recurrent episodes. In 2023, an implantable cardioverter-defibrillator was implanted due to frequent ventricular premature beats, and the patient was maintained on long-term oral medication, including sacubitril/valsartan, dapagliflozin, bisoprolol, vericiguat, torasemide, and spironolactone. One month ago, these symptoms had worsened and were not relieved by resting. The patient presented with lower extremity edema and fatigue and was observed to sit upright to facilitate breathing. He was subsequently hospitalized in the hospital’s cardiovascular department. The N-terminal pro-brain natriuretic peptide (NT-proBNP) level was 17,245 ng/L, and high-sensitive cardiac troponin (hs-cTnT) level was 0.074 µg/L. Chest x-ray showed pulmonary edema (Figure 1A). He received treatment for heart failure, including cardioprotective theraphy, diuresis to reduce the cardiac load, and other symptomatic treatments. His past medical history was unexceptional.

Echocardiography after admission revealed dilated cardiomyopathy, severe aortic regurgitation, mild-to-moderate mitral regurgitation, moderate tricuspid regurgitation, reduced left ventricular systolic function, and general reduction in ventricular wall motion, with an ejection fraction of 22% and a left ventricular end diastolic diameter (LVEDD) of 80 mm. Coronary computed tomographic angiography (CTA) suggested the presence of varying degrees of mild stenosis in all coronary arteries, with no significant lesions identified (Figure 1B). Aortic CTA suggested an aortic root aneurysm, with a maximum aortic diameter of up to 53 mm (Figures 1C,D). Right heart catheterization showed a central venous pressure (CVP) of 3 mmHg, mean pulmonary artery pressure of 29 mmHg, and a total pulmonary resistance of 1.35 Wood units.

The patient was admitted with a more serious presentation of the disease. Chest radiographs indicated worsening bilateral pulmonary exudates, and his blood pressure was found to be low. A moderate-to-medium dose of dopamine was administered to assist the heart in perfusing the body. The INTERMACS score was 3, low risk was indicated by a score of 2 points on the EUROMACS-RHF score, and the EuroSCORE II was 15.35. Following a period of medical management, heart failure symptoms were notably reduced, and his lung condition showed significant improvement. The patient met the criteria for a heart transplant, and our initial recommendation was for them to wait for the procedure. Generally, it is not advisable to combine complex procedures with LVAD implantation. However, due to the shortage of heart donors in China, the patient was at high risk of dying while waiting for a transplant. Furthermore, the patient had experienced repeated heart failure and had been hospitalized several times for treatment. Our team discussed treatment options with the relatives several times, and they expressed their desire for the surgery to be performed as soon as possible. Based on the patient's and their family's decision, our team decided to perform LVAD implantation concomitantly with the Bentall procedure for the patient.

After achieving general anesthesia, the right femoral artery was exposed. Subsequently, a median sternotomy was performed. Transesophageal echocardiography was used to identify the appropriate placement of the apex region. The cardiopulmonary bypass (CPB) was established by two-stage cannulation of the right atrium and femoral artery. A left ventricular drain was implanted through the right upper pulmonary vein. The ascending aorta was cross-clamped, and then the del Nido solution was perfused via the coronary orifice. The apex of the heart was elevated and exposed. The LVAD ring was then sewn on the marked region of the apex with teflon-pledged sutures (Figure 2A). The center of the sewing ring was incised using a punch. The left ventricle was then examined, after which thrombus and excess tissue were removed (Figure 2B). Thereafter, the inflow cannula was placed into the left ventricle. The outflow vascular graft was secured at its distal end (Figure 2C). The driveline was tunneled within the rectus muscle sheath.

The Bentall procedure was initiated. After excision of the aortic valve, an appropriately sized graft was selected, and then the bioprosthesis was sutured to the proximal end of the prosthetic graft to form a composite conduit. A separate 10-mm-diameter Dacron graft was trimmed to the appropriate length and anastomosed end-to-end to the left coronary orifice with a running 5-0 Prolene suture. The composite conduit was sewn into place at the aortic annulus with continuous 4-0 Prolene sutures (Figure 2D). The tissue around the right coronary orifice was released, and the right coronary artery was anastomosed end-to-side to the aortic graft directly (Figure 2E). Next, the latter conduit was anastomosed end-to-end to the distal of the aorta (Figure 2F). A partial cross-clamp was placed on the ascending aortic graft. The cuff was sewn around the anastomosis on the ascending graft using a continuous 4-0 Prolene suture. The outflow graft was cut obliquely, and then anastomosed end-to-side at the cuff with a running 4-0 Prolene suture (Figure 2G). The Cabrol shunt technique was performed to collect the bleeding from the perigraft space to the right atrium using artificial pericardium and the remaining vessel wall (Figure 2H). Rewarming and decannulation are then performed in a routine manner. While the LVAD achieved a pump flow of 2.78 L/min at 2,546 rpm, the patient was weaned from the CPB. The total CPB time was 332 min, and the cross-clamp time was 225 min. The patient was transferred to the ICU.

The patient exhibited oliguria on the first postoperative day (POD), accompanied by a rise in renal function index. The patient was placed on bedside continuous renal replacement therapy (CRRT). The patient's urine returned to a normal level on POD4. The patient was extubated on POD4. The patient had more pleural fluid postoperatively, which was deemed to be associated with exudate from the artificial vessel and the extensive surgical trauma. The drainage levels decreased, and the chest tube was subsequently removed on POD19. Heparin was administered, and the activated clotting time (ACT) was maintained at 160–200 s. The patient's warfarin was initiated on POD6, trying to maintain the international normalized ratio (INR) at 1.8–2.5. At 2 weeks postoperatively, the patient was able to ambulate and move without assistance. He was discharged on POD26 without any adverse events, while the LVAD achieved a pump flow of 3.08 L/min at 2,846 rpm. One year after the surgery, echocardiography revealed normal prosthesis function and reduced valve regurgitation, with an ejection fraction of 30% and an LVEDD of 68 mm (Figure 3). The chest x-ray taken 1 year after the patient was discharged from the hospital is shown in Figure 4.