A New Less Invasive Technique of RVAD Insertion - Time to Lower the Threshold around LVAD Insertion

Abstract

Purpose Temporary mechanical Right Ventricle(RV) support around planned LVAD implantation has always carried a substantial risk of mortality and morbidity. Historically insertion and removal of RVAD have been highly invasive. We use a less invasive variation of RV support concomitant with LVAD implantation. Methods Retrospective review of patient records who underwent temporary RVAD insertion along with LVAD insertion. The inflow cannula is an 8mm vascular graft on to the main pulmonary artery which is brought out through the second intercostal space and tunneled again under the skin for 10cm before the cannula exits. The drainage cannula could be in the neck or groin. A 25 Fr. cannula is inserted into the Right Internal Jugular Vein or the stump of the Saphenous Vein. When the RV has recovered, under the local anaesthesia the vascular graft is tied and the venous cannula is removed respectively. Results Over the past 3 years, 71 patients have undergone LVAD insertion (HVAD, Heartware II) at our institute; out of whom 14 (19.7%) required temporary RVAD support. The majority of these patients were male (78.5%) with a mean age of 49.7±12.2 years. 42.8 % of the patients had ischaemic cardiomyopathy, 35.7% had dilated cardiomyopathy and 21.4% had viral myocarditis. Most of the patients had deranged RV parameters preoperatively. Temporary RVAD support was instituted if the patient could not be weaned off Cardiopulmonary Bypass or had poor LVAD flows despite optimal inotropic support. The neck venous cannulation allowed for early patient mobilisation while still on the RVAD. The average duration of RVAD support was around 8.7±4.4 days. It is our standard practice to extubate patients while on RVAD, aggressively remove fluid either with Continuous Veno-Venous Haemofilteration or diuresis and inotropic support with a combination of Milrinone, Adrenaline and Levosimendan. We were able to successfully wean off, all our 14 patients from RVAD. Our long term follow-up reveals that 11 out of 14 patients (78.5%) are still alive and healthy. Two of these patients have already had their heart transplanted and the rest are enlisted for heart transplantation. We unfortunately lost 3 of the 14 patients - one each to VAD thrombosis, VAD related infection and multiorgan failure Conclusion Experience with this technique is highly encouraging and we plan to undertake a prospective study to validate this.