Invited Commentary

Abstract

Left ventricular assist devices (LVADs) have improved outcomes for many patients with end-stage heart disease. Nevertheless, there is a subset of patients with biventricular failure for whom left ventricular support alone is insufficient. Predicting which patients will have refractory right ventricular failure after LVAD implantation can be challenging. However, because a delay in appropriate right ventricle support can lead to irreversible organ failure and death, many centers elect to mechanically support the right ventricle in high-risk patients undergoing LVAD surgery. In this study, Arabía and colleagues [1Arabía F.A. Milano C.A. Mahr C. et al.Biventricular support with intracorporeal, continuous flow, centrifugal ventricular assist devices.Ann Thorac Surg. 2018; 105: 548-556Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar] used the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database to examine the outcomes of patients who had durable centrifugal continuous-flow (CCF) LVADs implanted in a biventricular configuration. This group was then compared with patients who had a temporary right ventricular assist device (RVAD) implanted at the time of LVAD surgery. Only 38 patients had biventricular durable devices reported over the period of this study. However, from the data available, the authors conclude that there is no difference between the temporary and durable implantable device groups in terms of overall survival or progression to transplantation. Although the numbers are small, this study serves as a much needed reference and will help to guide discussion about expected outcomes in patients who require biventricular mechanical support. That being said, the data supporting a durable LVAD implant in an RVAD configuration over a temporary RVAD are less convincing. The use of CCF LVADs in the RVAD configuration is tempting as it provides patients the opportunity for early ambulation and may be the only option for discharge home. These theoretic advantages, however, must be critically weighed against the high rates of device malfunction, which approach 30% in this series. One third of these required reoperation and pump exchange for presumed pump thrombosis. Certainly, there are temporary RVAD configurations that avoid femoral cannulation and patient immobility. Our preference for right ventricular support in a transplant candidate is to place temporary RVAD cannulas through tunneled thoracic grafts. This enables chest closure, early ambulation, and bedside decannulation in the event of right ventricle recovery. If CCF devices are to be used for right-side support, it is still unclear what the appropriate cannulation strategy should be. In this paper, it appears that a right atrial approach has a survival advantage over right ventricular cannulation, which is potentially related to device malfunction in the latter group. However, the sample size is too small to make meaningful conclusions at this point. Perhaps the most important point to be made about durable right-sided support is that the ideal pump does not yet exist. There is an opportunity for the development of RVADs that are specifically modeled for the unique characteristic of right-sided pressures and anatomy. Until that time, we will continue to benefit from studies such as this one that demonstrate clearly the outcomes of therapies for this complex patient population. Biventricular Support With Intracorporeal, Continuous Flow, Centrifugal Ventricular Assist DevicesThe Annals of Thoracic SurgeryVol. 105Issue 2PreviewThe incidence of right ventricular dysfunction requiring right ventricular assist device after left ventricular assist device placement has been reported between 10% to 30%. The mortality rate is higher compared with patients who require left ventricular assist device only; the most effective and safest biventricular assist device remains unknown. We aimed to determine the survival outcomes and frequency of adverse events in patients with two durable, intracorporeal, continuous flow centrifugal pumps for support. Full-Text PDF