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

Abstract

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.