Outcome of unplanned right ventricular assist device support for severe right heart failure after implantable left ventricular assist device insertion.

The use of a right ventricular assist device (RVAD) becomes necessary for severe right ventricular (RV) failure after left ventricular assist device (LVAD) insertion. Although temporary support could lead to successful RVAD weaning in certain patients, the data remain scarce. We retrospectively reviewed 398 patients who underwent implantable LVAD insertion between January 2000 and December 2012. Of these patients, 44 (11%) required unplanned RVAD support due to severe RV failure after LVAD insertion. For comparison, 37 patients who underwent planned biventricular assist device (BiVAD) insertion were identified during the same study period. We analyzed the early and late outcomes in these patients. The mean duration of RVAD support was 21 ± 23 days. Of the 44 patients, 21 (49%) were weaned from the RVAD (weaning group), whereas 23 (51%) required continued biventricular support (failure group). The failure group had ongoing end-organ dysfunction after RVAD insertion. Hospital mortality was significantly lower in the weaning group (24%) and in the planned BiVAD group (30%) as compared to the failure group (74%, p = 0.0009). The 6-month actuarial survival rate was 75% in the weaning group, 62% in the planned BiVAD group and 13% in the failure group (p < 0.0001). Successful bridge to transplant was achieved in 14 patients (67%) in the weaning group as compared with 8 patients (35%) in the failure group (p = 0.03). On multivariate logistic regression analyses, pre-operative white blood cell (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.04 to 1.50, p = 0.016) and creatinine (OR 0.26, 95% CI 0.079 to 0.88, p = 0.03) levels were significant predictors for RVAD removal. Among patients who developed acute RV failure after LVAD insertion, only half could be weaned from the temporary RVAD support. An alternative strategy is necessary in patients who require continuous RVAD support.

Takeda K ，Naka Y ，Yang JA ，Uriel N ，Colombo PC ，Jorde UP ，Takayama H ... -  《-》

Recovery of right heart function with temporary right ventricular assist using a centrifugal pump in patients with severe biventricular failure.

Long-term outcomes of a biventricular assist device (BiVAD) support are worse than those of an isolated left ventricular assist device (LVAD) support. This study evaluated our strategy for right heart failure using a temporary right VAD (RVAD) with an extracorporeal centrifugal pump. From January 2001 to December 2010, 108 patients underwent LVAD implantation at our institution and their clinical outcomes were studied. A temporary centrifugal RVAD was implanted in 26 patients. Multivariate logistic regression revealed pre-operative extracorporeal life support (odds ratio [OR], 37.0), central venous pressure (OR, 1.2), mean pulmonary artery pressure (OR, 0.9), and serum total bilirubin (OR, 1.4) were the risk factors for RVAD requirement. RVAD-off test was conducted, and 11 of the 26 patients showed significant recovery of right heart function and were eventually removed from RVAD support. The survival of patients with isolated LVAD was significantly better than those with a paracorporeal pulsatile BiVAD (80% vs 11% at 1 year, p < 0.001). However, there was no significant difference between the survival of patients who underwent isolated LVAD support and those who were initially implanted with temporary BiVAD but underwent the RVAD removal (80% vs 73% at 1 year, p = 0.827). Our strategy with temporary RVAD for severe acute right heart failure was effective in selecting the patients who could be weaned from RVAD support. Patient survival was improved by avoiding the long-term support with a paracorporeal pulsatile BiVAD.

Saito S ，Sakaguchi T ，Miyagawa S ，Nishi H ，Yoshikawa Y ，Fukushima S ，Daimon T ，Sawa Y ... -  《-》

Temporary right ventricular support following left ventricle assist device implantation: a comparison of two techniques.

Right ventricular failure (RVF) after implantation of left ventricular assist device (LVAD) is a dramatic complication. We compared retrospectively two techniques of temporary right ventricular support after LVAD (HeartMate II, Thoratec Corp, Pleasonton, CA, USA) implantation. From 1 January 2006 to 31 December 2012, 78 patients [mean age 52 ± 1.34 years; 15 women (19%)] received a HeartMate II at our institution. Among these, 18 patients (23%) suffered postimplant RVF treated by peripheral temporary right ventricular support. Aetiology of heart failure was ischaemic in 12 (67%) and dilated cardiomyopathy in 6 (33%) patients. The preimplant RV risk score averaged 5.1 ± 0.59. Ten patients were treated using a femorofemoral venoarterial extracorporeal life support (ECLS) and 8 patients were treated using extracorporeal membrane oxygenation as a right ventricular assist device (RVAD) established between a femoral vein and the pulmonary artery via a Dacron prosthesis (RVAD). Duration of RV support was 7.12 ± 5.4 days and 9.57 ± 3.5 days in venoarterial ECLS and vein and the pulmonary artery RVAD groups, respectively (P = 0.32). Three patients (17%) died while under RV support (venoarterial ECLS, n = 2; and vein and the pulmonary artery RVAD, n = 1, P = 0.58). In the venoarterial ECLS group, 6 (60%) patients suffered major thromboembolic complications including thrombosis of the ECLS arterial line (n = 2), ischaemic stroke (n = 2) and thrombosis of the ascending aorta (n = 2). No major complication was observed in the vein and the pulmonary artery RVAD group (P = 0.01). RV support was successfully weaned in 8 (80%) patients of the venoarterial ECLS group and in 7 (87.5%) of the vein and the pulmonary artery RVAD group (P = 0.58). The duration of postimplant intensive care unit stay was not different (respectively, 27.5 ± 18.7 days and 20.0 ± 12.0 days; P = 0.38) between both groups. Temporary support of the failing RV after LVAD implantation using temporary vein and the pulmonary artery RVAD is a promising therapeutic option. This approach provides adequate LVAD pre- and afterload and is associated with significantly less thromboembolic complications.

Noly PE ，Kirsch M ，Quessard A ，Leger P ，Pavie A ，Amour J ，Leprince P ... -  《-》

Survival after left ventricular assist device with and without temporary right ventricular support.

Right ventricular (RV) failure after the insertion of a left ventricular assist device (LVAD) historically results in poor outcomes. Patients requiring temporary RV support after LVAD insertion are a heterogeneous group of patients consisting of those in cardiogenic shock after myocardial infarction, to those with chronic decompensated heart failure. For patients requiring biventricular support, we have used a hybrid system consisting of a HeartMate II LVAD and CentriMag right ventricular assist device (RVAD). The purpose of this study was to determine the 1-year survival in patients requiring isolated LVAD and patients requiring biventricular support. All patients who underwent HeartMate II LVAD alone or in conjunction with a temporary CentriMag RVAD were examined from 2006 to 2011. Preoperative demographics, operative outcomes, and survival were analyzed. A total of 139 patients required HeartMate II insertion; 34 (24%) required biventricular support at the time of HeartMate II implantation. The mean duration of biventricular support was 17 ± 11.9 days (range, 6 to 56 days) with 91.8% (n = 31) of RVADs successfully explanted. Survival to hospital discharge was not different between groups (95.2 versus 88.2%; p = 0.2). However, 1-year survival was significantly greater in patients who required isolated HeartMate II LVAD (87% versus 77%; p = 0.03). Biventricular support using a HeartMate II LVAD and CentriMag RVAD resulted in limited mortality at hospital discharge. However biventricular dysfunction does not have a favorable outcome at 1 year when compared with patients requiring isolated HeartMate II.

Lazar JF ，Swartz MF ，Schiralli MP ，Schneider M ，Pisula B ，Hallinan W ，Hicks GL Jr ，Massey HT ... -  《-》

Contemporary outcome of unplanned right ventricular assist device for severe right heart failure after continuous-flow left ventricular assist device insertion.

The timely use of a right ventricular assist device (RVAD) becomes necessary for severe right heart failure (RHF) after left ventricular assist device (LVAD) insertion. This study evaluates outcomes in patients who required unplanned RVAD support early after continuous-flow (CF) LVAD insertion. We retrospectively reviewed 305 patients who underwent HeartMate II/HeartWare CF-LVAD insertion between 2009 and 2014. Twenty-seven (9%) patients required unplanned RVAD for severe RHF early after LVAD insertion. We compared early and late outcomes in patients with and without RVAD. The median time to RVAD implantation after primary CF-LVAD implantation was 1.0 (0-3) day. Seventeen (63%) patients could be weaned from RVAD after median of 14 (10-18) days. In 278 patients in the isolated LVAD group, overall survival at 3 and 12 months was 95% and 86%, whereas 59% and 54% in the unplanned RVAD group, respectively ( P  < 0.001). The 12-month overall survival rate in patients who were weaned from RVAD was 75% ( P  = 0.189 vs isolated LVAD group), whereas in patients who could not be weaned from RVAD, the overall survival was 20% ( P  < 0.001 vs RVAD weaning group and isolated LVAD group). Readmission free rate for RHF at 1 year was 53% in the unplanned RVAD group and 90% in the isolated LVAD group ( P  = 0.002). Among patients who required unplanned RVAD after CF-LVAD implantation, above 60% of the patients could be weaned from RVAD. However, careful attention should be paid to the recurrent or sustained RHF.

Yoshioka D ，Takayama H ，Garan RA ，Topkara VK ，Han J ，Kurlansky P ，Yuzefpolskaya M ，Colombo PC ，Naka Y ，Takeda K ... -  《-》