A Novel Technique for Temporary Right Ventricular Support Using the Existing Cardiopulmonary Bypass Circuit During LVAD Implantation

Abstract

<h3>Purpose</h3> Right heart failure following implantation of left ventricular assist devices (LVADs) occurs in 9-42% of patients. A variety of predictive models allow for selection of patients at high-risk for early RV failure. We sought to develop a technique to provide temporary right heart support using a centrally cannulated cardiopulmonary bypass (CPB) circuit during the LVAD implantation procedure. <h3>Methods</h3> Patients at high-risk for RV failure during LVAD implantation were supported by a modified CPB circuit. The objective was to separate from CPB without the need for a percutaneous or durable right ventricular assist device (RVAD). A standard CPB circuit was altered to include three bridges with the ability to exclude the venous reservoir, oxygenator, and arterial filter (Figure 1). Prior to weaning from CPB, a cannula was placed into the main pulmonary artery and connected to the arterial limb. This configuration enabled the circuit to easily transition between standard CPB, a RVAD, or both. Following wean from CPB and reversal of coagulopathy, the RVAD configuration allowed for delivery of blood while supporting the RV. <h3>Results</h3> From 2019 to 2021 four patients were identified at a single institution. Pre-operative mean clinical values included central venous pressure (CVP) of 16mmHg ± 3.9, pulmonary capillary wedge pressure (PCWP) of 25.3mmHg ± 2.8, tricuspid annular plane systolic excursion (TAPSE) of 1.2cm ± 0.28, right ventricular stroke work index (RVSWI) of 315 ± 41.2, and CVP/PCWP 0.63 ± 0.11. All patients were successfully weaned from CPB to LVAD support at the time of surgery. <h3>Conclusion</h3> We present a novel method of CPB weaning during LVAD implantation that allows for RV support. This configuration is easy to implement using a standard CPB circuit and serves as an immediate bridge for patients at high-risk for early RV failure. Furthermore, this technique avoids the RV strain that occurs with volume resuscitation while weaning from CPB and correcting coagulopathy.