How to Heal a Broken Heart with Time and a Hybrid Mechanical Circulatory Support Armada

Abstract

<h3>Introduction</h3> Continuous flow VADs are used as left ventricular assist devices (LVAD) with an off-label option as right ventricular assist device (RVAD). The Berlin Heart® EXCOR is a paracorporeal, pulsatile ventricular assist device (VAD) used for right-, left- or biventricular support. While inotropes are is the first-line treatment in patients in acute cardiogenic shock, mechanical circulatory support (MCS) in that setting has evolved and different devices are available. <h3>Case Report</h3> A 59-year-old male patient was admitted in 06/2020 for inferior pericardiectomy due to hemodynamic instability after right ventricular (RV) lead dislocation with pericardial effusion. He presented severely impaired biventricular function with indication for Impella® 5.5 implantation. With further RV deterioration, a temporary RVAD with a ProtekDuo®canula + CentriMag^TM pump was implanted. The patient was weaned from nitric oxide (NO) inhalation and extubated on the first postoperative day (POD). However, he developed hyperbilirubinemia with Bilirubin > 13 mg/dl under full t-RVAD support and continuous inotrope therapy, with acute-on-chronic renal failure leading to anuria. High urgent listing for transplantation (HTX) was not an option in this clinical situation. The patient gave consent to biventricular assist device (BIVAD) implantation. On POD 19 after pericardiectomy, a HeartMate 3^TM LVAD in a hybrid combination with a Berlin Heart® Excor RVAD was successfully implanted. He was weaned from NO and extubated within 24 hours. On POD 3 after BIVAD, a right ventricular chamber upgrade to a 80ml chamber was performed. After 4 weeks on BIVAD support, the patient developed a haemothorax with need for surgical revision due to overanticoagulation. Thereafter, he slowly recovered and could be discharged from ICU to the normal care ward after 92 days. He has been free from dialysis since 11/2020 and was discharged home with a Berlin Heart®Excor mobile in 12/2020. Active listing for HTX was granted in 06/2021, one year after first admission. The patient is now stable in NYHA 3 with BIVAD support at home. <h3>Summary</h3> Treatment options in biventricular failure are limited. In countries with long waiting list time, hybrid BIVAD support with a continuous flow LVAD and a pulsatile paracorporeal RVAD is feasible and allows successful discharge. Further research is needed to evaluate this clinical approach.