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• W1891353144 abstract "Increased use of continuous-flow left ventricular assist devices (LVADs) to treat advanced heart failure has heightened concern for right ventricular failure after LVAD implantation, which is associated with increased morbidity and mortality. Biventricular support is required in up to 30% of LVAD recipients. Currently, no durable long-term right ventricular assist device (RVAD) has been approved other than the Syncardia (Tucson, AZ) total artificial heart. A recent publication reported the placement of continuous flow LVAD in the heavily trabeculated right ventricle; however, this orientation may jeopardize both assist device and right ventricle function. We describe three cases of right-sided mechanical circulatory support with durable RVAD implanted in the right atrium, allowing long-term support with fewer anatomic limitations as compared with right ventricular cannulation. Increased use of continuous-flow left ventricular assist devices (LVADs) to treat advanced heart failure has heightened concern for right ventricular failure after LVAD implantation, which is associated with increased morbidity and mortality. Biventricular support is required in up to 30% of LVAD recipients. Currently, no durable long-term right ventricular assist device (RVAD) has been approved other than the Syncardia (Tucson, AZ) total artificial heart. A recent publication reported the placement of continuous flow LVAD in the heavily trabeculated right ventricle; however, this orientation may jeopardize both assist device and right ventricle function. We describe three cases of right-sided mechanical circulatory support with durable RVAD implanted in the right atrium, allowing long-term support with fewer anatomic limitations as compared with right ventricular cannulation. Right ventricular (RV) failure is a common condition after ventricular assist device placement. It is difficult to predict and is associated with high morbidity and mortality. Current therapeutic options for patients with RV failure include both temporary and durable ventricular support, as well as the total artificial heart. The use of continuous-flow centrifugal devices implanted on the right side have been recently proposed as an alternative therapy for RV support, although more research is required to validate this approach. Durable biventricular assist device implantation is feasible, and the operative approach to this type of support is currently not well elucidated. A 19-year-old white woman without medical history with a recent viral prodrome presented in acute decompensated heart failure with rapid deterioration. Echocardiographic and invasive hemodynamic results (Table 1) were concerning for biventricular failure. Endomyocardial biopsy was consistent with lymphocytic myocarditis. After failing inotropic support, she underwent urgent left ventricular assist device (LVAD) implantation using a HeartWare HVAD (HeartWare International, Framington, MA) as a bridge to cardiac transplantation. Preoperatively, there was concern for RV failure (Table 1). With inotropic, vasopressor, inhaled nitric oxide, and LVAD support, separation from cardiopulmonary bypass was achieved, but transesophageal echocardiography (TEE) revealed a poorly contracting and dilated RV. After attempted chest closure, RV failure and cardiogenic shock developed, necessitating a return to cardiopulmonary bypass. A HeartWare HVAD was then placed for RV support. The inflow cannula in the right atrium was distracted with a 1-cm felt gasket, and the 15-cm outflow graft was sewn end-to-side onto the main pulmonary artery. Separation from bypass was successful with biventricular continuous flow support. The LVAD and RV assist device (RVAD) was optimized with TEE and set to 2700 and 2000 rpm, respectively, to maintain a neutral position of both the atrial and ventricular septa. Total cardiopulmonary bypass time was 153 minutes, and no cardiac arrest was required.Table 1Echocardiography and Invasive Hemodynamics in Pre-VAD WorkupModalityIndicesCase 1Pre-VADCase 2Pre-VADCase 3Pre-VADEchocardiographyLVEF (%)142318LVEDd (cm)6.96.38.5RVSP (mm Hg)193154TAPSE (cm)1.171.211.21Invasive hemodynamicsCVP (mm Hg)232010mPAP (mm Hg)383834PCWP (mm Hg)353422Cardiac index (L/min/m2)1.51.21.5PVR (WU)1.11.82.6RVSWI (g*m/m2)2.03.44.4LVEF = left ventricular ejection fraction; LVEDd = left ventricular end-diastolic diameter; mPAP = mean pulmonary arterial pressure; PCWP = pulmonary capillary wedge pressure; PVR = pulmonary vascular resistance; RSVP = right ventricular systolic pressure; RVSWI = right ventricular stroke work index; TAPSE = tricuspid annular plane systolic excursion; VAD = ventricular assist device. Open table in a new tab LVEF = left ventricular ejection fraction; LVEDd = left ventricular end-diastolic diameter; mPAP = mean pulmonary arterial pressure; PCWP = pulmonary capillary wedge pressure; PVR = pulmonary vascular resistance; RSVP = right ventricular systolic pressure; RVSWI = right ventricular stroke work index; TAPSE = tricuspid annular plane systolic excursion; VAD = ventricular assist device. The patient was extubated on postoperative day 1, and within 7 days was ambulatory with New York Heart Association (NYHA) class II symptoms. Seventeen days after biventricular assist device (BiVAD) support (on hospital day 26), she underwent successful orthotopic heart transplantation. The posttransplant course was uncomplicated, and she was discharged home on hospital day 40. A 49-year-old black male with a history of nonischemic cardiomyopathy, congestive hepatopathy, chronic renal insufficiency, and severe malnutrition was referred to our institution for treatment of advanced heart failure. Echocardiographic and invasive hemodynamic results (Table 1) prompted concern for biventricular failure. Moreover, a hepatic biopsy demonstrated mild bridging fibrosis without cirrhosis. The patient underwent left ventricular HeartWare HVAD on hospital day 41. Intraoperative TEE and invasive hemodynamics revealed evidence of RV dysfunction (Table 1). Despite aggressive medical therapy, he remained hypotensive with low cardiac output and elevated right-sided filling pressures and low LVAD flows. A second HeartWare HVAD was therefore implanted with the inflow cannula in the right atrium. A 15-cm segment of the standard 10-mm outflow graft was sewn end-to-side to the main pulmonary artery. A 5-0 Prolene suture was used to narrow the graft down to 8 mm over a 4-cm segment in an attempt to provide more resistance to flow and to allow a wider range of speed settings on the RVAD. Total cardiopulmonary bypass time was 165 minutes, and no cardiac arrest was required. Intraoperative TEE optimized LVAD and RVAD speeds (2400 and 2000 rpm, respectively), aiming for a neutral position of both the intraatrial and intraventricular septa. The patient was extubated on postoperative day 1. With recovery of renal function and independent management of his BiVAD, he was discharged home on postoperative day 42, at status 7 on the transplant list while awaiting complete nutritional recovery. He remained clinically stable with NYHA class II symptoms without evidence of pump thrombosis or need for readmission for over 180 days, and he is now status-post successful orthotopic heart transplantation. A 42-year-old man with a history of nonischemic cardiomyopathy and moderate aortic regurgitation was admitted in cardiogenic shock. Echocardiography and hemodynamic studies are detailed in Table 1. One week after aggressive diuresis and inotropic support, the patient underwent aortic valve repair and implantation of an HeartWare LVAD as a bridge to transplant. Intraoperatively the RV was enlarged with poor function on invasive hemodynamic testing, indicating a low likelihood of a successful weaning from cardiopulmonary bypass; therefore, so RVAD support via a right atrial approach with implantation of a HeartWare RVAD was provided, as described for Patients 1 and 2. Total cardiopulmonary bypass time was 240 minutes, and no cardiac arrest was required. The LVAD speed was set at 2,640 rpm and the RVAD was set at 2,420 rpm. He was extubated on postoperative day 1 and was discharged on postoperative day 16. Twenty-seven days after BiVAD implantation, he presented in rapid ventricular tachycardia in the setting of hypokalemia, but with stable BiVAD flows. Following cardioversion, he remains clinically stable with NYHA class II-III symptoms without evidence of pump thrombosis. Right ventricular failure after implantation of an LVAD is associated with increased morbidity and mortality and heart failure hospitalizations following LVAD [1Stewart G.C. Givertz M.M. Mechanical circulatory support for advanced heart failure: patients and technology in evolution.Circulation. 2012; 125: 1304-1315Crossref PubMed Scopus (153) Google Scholar, 2Krabatsch T. Potapov E. Stepanenko A. et al.Biventricular circulatory support with two miniaturized implantable assist devices.Circulation. 2011; 124: S179-S186Crossref PubMed Scopus (159) Google Scholar]. Patients with RV failure despite aggressive medical therapy may stand to benefit from long-term, durable, right-sided mechanical circulatory support [1Stewart G.C. Givertz M.M. Mechanical circulatory support for advanced heart failure: patients and technology in evolution.Circulation. 2012; 125: 1304-1315Crossref PubMed Scopus (153) Google Scholar, 3Patel C.B. Cowger J.A. Zuckermann A. A contemporary review of mechanical circulatory support.J Heart Lung Transplant. 2014; 33: 667-674Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar]. Previous work describes durable ventricular assist device implantation with the inflow cannula in the RV, but this approach has significant drawbacks, including obstruction of flow by the tricuspid valve or subvalvular apparatus and potential external compression of the RV. Right atrial cannulation of a durable VAD has been described previously in one patient [4Hetzer R. Krabatsch T. Stepanenko A. Hennig A. Potapov E.V. Long-term biventricular support with the HeartWare implantable continuous flow pump.J Heart Lung Transplant. 2010; 29: 822-824Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar] who did not tolerate RV implantation because of compression caused by the inflow cannula. We describe three patients with Interagency Registry for Mechanically Assisted Circulatory Support Profile 1-2 in which this strategy was used for right-sided circulatory support. This approach offers several advantages. The standard inflow cannula connecter is distracted from the right atrial wall by a 1-cm felt ring gasket and is aimed toward the tricuspid valve. The outflow graft can be narrowed to 8 mm over a 4-cm segment to provide more resistance, allowing for higher speed settings on the RVAD if low pulmonary vascular resistance is encountered. This was not required for Patient 1, possibly because of the longer outflow graft (∼15cm) seen with the atrial configuration. Should RV function recover adequately to wean from RVAD support, the RVAD inflow cannula can potentially be occluded in the catheterization laboratory and allowed to thrombose. The RVAD driveline can then be cut at the skin and closed over, freeing the patient from one system; an abandoned atrial RVAD should not interfere with RV function. These cases illustrate a novel operative approach using a right atrial inflow cannula, allowing long-term biventricular circulatory support using two HeartWare HVADs. More data are needed to evaluate the efficacy of this approach as a long-term solution for patients with biventricular failure, as presently there is no standard of care." @default.
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• W1891353144 date "2015-10-01" @default.
• W1891353144 modified "2023-09-26" @default.
• W1891353144 title "A Case Series of Biventricular Circulatory Support Using Two Ventricular Assist Devices: A Novel Operative Approach" @default.
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