Can Perioperative Right Ventricular Support Prevent Postoperative Right Heart Failure in Patients With Biventricular Dysfunction Undergoing Left Ventricular Assist Device Implantation?

Depending on the pre-existing condition of the right ventricle (RV), left ventricular assist device (LVAD) implantation may have a detrimental effect on RV function, subsequently leading to right heart failure. This study details the authors' experience with perioperative mechanical RV support in patients with biventricular impairment but primarily scheduled for isolated LVAD implantation. Retrospective study. Two center study, university hospital. This study included LVAD recipients with preoperative biventricular impairment who received an additional right ventricular assist device (RVAD) after a failed weaning attempt from cardiopulmonary bypass due to acute RV failure. Outcomes of 25 patients who underwent LVAD and unplanned temporary RVAD implantation were analyzed. All patients experienced significant preoperative RV impairment (tricuspid annular plane systolic excursion: 10.2±26.3 mm; right atrium pressure: 17.9±10.4 mmHg) and pulmonary hypertension (pulmonary artery pressure: 54.8±25.7 mmHg). In 15 patients, additional tricuspid valve annuloplasty was performed. Mean duration of temporary RVAD support was 11.1±7.2 days. In 23 patients (92%), the RVAD was removed successfully. None of the patients developed RV failure after RVAD removal. Hospital survival and the 1-year survival rate of the study group were 68% and 56%, respectively. The results of perioperative RVAD support in LVAD recipients with biventricular dysfunction are encouraging. Temporary RVAD support allows an already compromised RV to become attuned to the hemodynamic conditions after LVAD implantation. This strategy provides patients with preoperative impaired RV function a high likelihood to permanently undergo LVAD support only.

Deschka H ，Holthaus AJ ，Sindermann JR ，Welp H ，Schlarb D ，Monsefi N ，Martens S ，Scherer M ... -  《-》

Extracorporeal membrane oxygenation as perioperative right ventricular support in patients with biventricular failure undergoing left ventricular assist device implantation.

Left-ventricular assist device (LVAD) implantation complicated by early right ventricle (RV) failure has a poor prognosis. This study details our center's experience with veno-arterial extracorporeal membrane oxygenation (ECMO) as perioperative RV support in patients with preoperative biventricular failure undergoing LVAD implantation. Ten patients, who underwent LVAD implantation, were retrospectively analyzed. Six patients were already supported with ECMO before LVAD implantation. In four patients, the ECMO was implanted before weaning from cardiopulmonary bypass. All patients showed reduced RV function with elevated right-ventricular end-diastolic diameter (RVEDD) (38 ± 4 mm) and RV systolic pressure (48 ± 14 mmHg). The mean pulmonary artery pressure (PAP) was 36 ± 9 mmHg. Nine patients showed dilatation of the tricuspid annulus (≥ 35 mm) with moderate tricuspid valve insufficiency and received tricuspid valve annuloplasty. After removal of the ECMO, none of the patients developed RV failure. ECMO was removed 4±1 days after LVAD implantation. Four patients expired while on LVAD support due to not-device-related sepsis (two patients), mesenteric ischemia (one patient), and gastrointestinal bleeding (one patient), respectively. Overall survival was 60%. ECMO provided a satisfactory perioperative right-heart support in patients with preoperative biventricular failure undergoing LVAD implantations, who otherwise were better candidates for biventricular assist device. ECMO allowed time for the already compromised right ventricle to get attuned to the increasing preload, and avoids distension and RV failure.

Scherer M ，Sirat AS ，Moritz A ，Martens S ... -  《-》

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 ... -  《-》

Pulmonary Bleeding During Right Ventricular Support After Left Ventricular Assist Device Implantation.

Right heart failure still occurs in up to 20% of patients after implantation of a left ventricular assist device (LVAD). One treatment option for these patients is the implantation of a temporary right ventricular assist device (RVAD). Experimental data suggest that non-pulsatile perfusion of the lungs is associated with an increased rate of pulmonary hemorrhage. The aim of this study was to determine the incidence of pulmonary bleeding complications in these patients. Observational study. Single center, university hospital. This study included patients undergoing LVAD implantation for end-stage heart failure and subsequent implantation of a temporary right ventricular support system. In this study, 25 patients who underwent LVAD and additional temporary RVAD implantation were screened for pulmonary bleeding complications. The mean Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level at the time of LVAD implantation was 2.84. All patients experienced severe right ventricular failure (tricuspid annular plane systolic excursion [TAPSE], 10.16±26.3 mm) and severe pulmonary hypertension (right atrial [RA] pressure, 56.21±15.58 mmHg). Average duration of right ventricular support was 11.12±7.20 days, with right ventricular support being administered to 14 patients for more than 7 days. Seventeen patients were weaned successfully from right ventricular support after a mean support duration of 5 days. Five patients developed pulmonary bleeding complications, diagnosed using computed tomography scan and bronchoscopy. All bleeding occurred after postoperative day 7 and was associated with RVAD flow of more than 4 L/min within 24 hours before bleeding occurred. The data presented in this study suggested that right ventricular support for more than 7 days and a blood flow greater than 4 L/min were associated with pulmonary bleeding complications. This should be taken into consideration when temporary right ventricular support after LVAD implantation is planned.

Welp H ，Sindermann JR ，Deschka H ，Martens S ，Scherer M ... -  《-》

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 ... -  《-》