Invited Commentary

Abstract

There is an ongoing debate for optimal device selection in patients with acute heart failure requiring mechanical cardiac assist systems. Options reach from short-term univentricular support up to complete heart replacement devices. Implantable, durable, continuous-flow pumps have revolutionized left ventricular assist device (LVAD) long-time support by low complication and excellent survival rates. Heterogeneity of underlying cardiac problems challenge appropriate and optimal device selection or possible device combinations, especially in patients with refractory cardiogenic shock and expected but unknown recovery potential of the right ventricle (RV). In these patients, primary implantation of a pulsatile biventricular assist device or a total artificial heart might be invasive overtreatment, and isolated LVAD support alone might result in undertreatment in both situations, with different, but high risks for possible devastating complications. Lazar and colleagues [1Lazar J.F. Swartz M.F. Schiralli M.P. et al.Survival after left ventricular assist device with and without temporary right ventricular support.Ann Thorac Surg. 2013; 96: 2155-2160Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar] show their excellent clinical results over 5 years with temporary biventricular assist devices in a hybrid approach using two different support systems, the HeartMate II (Thoratec, Pleasanton, CA) LVAD in combination with the CentriMag (Levitronix, Waltham, MA) RVAD. They showed in patients with increased risk of right heart failure that short-term RVAD use during LVAD implantation improves survival dramatically, decreases potential postoperative circulatory collapse, and avoids subsequent emergent RVAD implantation with known severely decreased outcome. Their surgical treatment concept with well-defined preoperative and intraoperative assessment of the RV and LV, foresighted cannulation techniques, and prompt closure of the chest after the operation allows early recovery and deescalates intensive care treatment. After RV recovery, the RVAD weaning process can be accomplished under controlled circumstances, and explantation of the outflow graft can be performed by a less invasive minithoracotomy; again, allowing the patients to recover faster and to maintain nonintensive care status more early. Their initially more invasive hybrid biventricular assist device concept results in a less invasive and safer postoperative treatment. Finally, at 1 year, these high-risk patients nearly reach the excellent survival results of lower-risk patients with primary LVAD therapy only. In conclusion, a “more liberal” use of temporary RVAD in acute cardiac shock patients is highly recommended: when in doubt—pump! Survival After Left Ventricular Assist Device With and Without Temporary Right Ventricular SupportThe Annals of Thoracic SurgeryVol. 96Issue 6PreviewRight ventricular (RV) failure after the insertion of a left ventricular assist device (LVAD) historically results in poor outcomes. Patients requiring temporary RV support after LVAD insertion are a heterogeneous group of patients consisting of those in cardiogenic shock after myocardial infarction, to those with chronic decompensated heart failure. For patients requiring biventricular support, we have used a hybrid system consisting of a HeartMate II LVAD and CentriMag right ventricular assist device (RVAD). Full-Text PDF