Acute Right Ventricular Failure Research Articles

ADVANCED CARDIAC IMAGING IN LIVER TRANSPLANTATION ECHOCARDIOGRAPHIC VENTRICULAR STRAIN AS PROGNOSTIC TOOLS

Abstract While cardiac involvement in the end–stage liver disease (ESLD) is a known condition, the characteristics of cardiac function in cirrhotic cardiomyopathy and their effects on candidates to liver transplant (LT) are still vague. The evaluation of right ventricular failure (RVF) in liver transplant candidates has been revolutionized by advanced cardiac imaging techniques, particularly echocardiography with global longitudinal strain (GLS) analysis. Aim of the present study is to evaluate RV function indexes in ESLD patients candidate to LT and the potential relationship with the liver disease status and cardiovascular major events on early post–LT phase Forty ESDL adult patients (age 46.8 ± 10 yrs, M/F 33/7) candidate to LT (19 for hepatic failure, 18 for hepatocarcinoma and 3 for other causes) were evaluate. All were submitted to transthoracic echocardiography and coronary CT angiography or coronary angiography. The Model for End–stage Liver Disease (MELD) score in the study population was 19±6.8. The higher values of the MELD score (i.e. the worst liver function condition) were directly correlated with the lower RV–GLS (p<0.02). Cardiac function indexes were LV–EF 62.8±4.5%, RV–GLS –22.9±4.5%, LV–GLS –19.5±4.6% and PAPs 31.8±6.6 mmHg. On 21 day follow–up, 4 patients died (2 with acute RV failure, 1 with Tako–Tsubo syndrome). On CT–angiography the value of calcium score was significantly different between the group of fatal events and the rest (0 vs 567±900), revealing that none of the died patient suffered from coronary atheromatic disease. Our findings identified that specific RV–GLS patterns on echocardiography, indicative of subclinical myocardial dysfunction, were strongly correlated with worst clinical hepatic conditions and reduced survival rates post–transplant. The study highlights the importance of advanced cardiac imaging in identifying liver transplant candidates at higher risk of post–transplant mortality due to RHF.

Rescuing the Right Ventricle: Mechanical Support After Pediatric Heart Transplantation

BackgroundRight ventricular (RV) failure after heart transplantation (HT) is common in those with pretransplantation elevated pulmonary vascular resistance (PVR). Mechanical circulatory support has been used as a bridge to recovery, with mixed outcomes. We describe a patient with failed single-ventricle palliation in whom severe RV failure developed after HT. We review the current literature and outline our post-HT strategy. MethodsAn infant with trisomy 21, severely unbalanced right dominant atrioventricular septal defect, and hypoplastic aortic arch was palliated with a hybrid procedure. At 6 months of age, cardiac catheterization measured PVR index of 5.47 Wood units × m2 on maximal medical therapy. The patient was deemed unsuitable for second-stage palliation and underwent HT at 18 months of age. Despite preemptive medical therapies, acute RV failure developed, necessitating extracorporeal membrane oxygenation. He was quickly converted to main pulmonary artery to left atrial cannulation. Unloaded RV function normalized; he was weaned from support and discharged home 5 weeks after HT. ResultsFailure of medical therapy in RV failure after HT requires escalation to mechanical circulatory support. We review the literature on RV failure and support after HT. We also describe a novel cannulation strategy to provide a reliable way to directly reduce RV afterload, to allow physiologic training of the right ventricle to a higher PVR, and to maintain normal left ventricular coupling and loading. ConclusionsIn pediatric patients with elevated PVR undergoing HT, advanced therapies can be used effectively to treat acute RV failure. Unique cannulation strategies may play a role in improving survival of similar patients.

Abstract 16077: Aortic Valve Thrombus and Acute Right Ventricular Failure in Recent Left Ventricular Assist Device Recipient: A Rare Case

Case reports of aortic root thrombus with embolism leading to right ventricular (RV) failure in patients left ventricular assist devices (LVAD) are extremely rare in the literature, and often result in significant mortality. This is a case of a 52-year-old male who recently underwent destination-therapy HeartMate 3 LVAD implantation, on chronic warfarin, with history of non-ischemic cardiomyopathy, atrial fibrillation, and heparin-induced thrombocytopenia, who presented with chest pain and dyspnea. Initial evaluation was remarkable for tachycardia, troponin of 0.7 ng/dl, BNP 705, and INR 1.68. Argatroban was initiated, along with diuresis for volume overload on examination. Transthoracic echocardiogram showed stable findings with borderline RV dysfunction. On the following day, persistent chest pain and uptrend of troponin to 34 ng/dl were concerning for acute coronary syndrome (ACS), and plans were for left heart catheterization. However, a TEE revealed partial thrombus layering in the aortic valve and sinus of Valsalva with concerns for embolization through the right coronary ostia. RV assessment showed evidence of severe dilation and acute RV failure. Patient underwent emergent RV assist device (RVAD) placement (ProtekDuo and CentriMag) by cardiothoracic surgery. After mechanical RV support, there was progressive improvement of its function, and successful RVAD decannulation was attained. The patient was recently seen in the heart failure clinic with sustained recovery. Cases of aortic root thrombus with embolism leading to ACS in LVAD patients are extremely rare. As in our case, troponin elevation, subtherapeutic INR, and aortic root thrombus, allowed early clinical recognition and appropriate management of patient’s RV failure, which is imperative for successful outcomes in LVAD patients. Aortic valve thrombus should be considered in LVAD patients presenting with ACS, and early invasive strategy without valve assessment should be cautioned.

Timing, positioning and ancillary therapies: the triad for successful Impella RP.

Clear clinical guidelines for the assessment and treatment of right ventricular failure (RVF) remain an unmet need. Although high complexity patients are common in this setting, the ideal management remains uncertain, resulting in high mortality rates despite presumably optimal medical therapy. Timely treatment with Impella RP may offer benefits by supplying circulatory support during the acute RVF phase and providing the time and unloading necessary for native right heart recovery. As such, mastering the technicalities and ancillary therapies is crucial to best utilize this salvage opportunity, particularly in these high complexity patients. Here, we report three different clinical scenarios of medically refractory RVF supported with Impella RP to provide examples and discuss the contribution of mechanical RV support to patient outcomes.

Management of Acute Right Ventricular Failure.

Acute right ventricular failure (RVF) is a frequent condition associated with high morbidity and mortality. This review aims to provide a current overview of the pathophysiology, presentation, and comprehensive management of acute RVF. Acute RVF is a common disease with a pathophysiology that is not completely understood. There is renewed interest in the right ventricle (RV). Some advances have been principally made in chronic right ventricular failure (e.g., pulmonary hypertension). Due to a lack of precise definition and diagnostic tools, acute RVF is poorly studied. Few advances have been made in this field. Acute RVF is a complex, frequent, and life-threatening condition with several etiologies. Transthoracic echocardiography (TTE) is the key diagnostic tool in search of the etiology. Management includes transfer to an expert center and admission to the intensive care unit (ICU) in most severe cases, etiological treatment, and general measures for RVF.

Experience with percutaneous right ventricular support in the early post-left ventricular assist device implantation period (clinical case report and literature reviews)

Implantable left ventricular assist device (LVAD) is a state-of-the-art treatment for adults and children with end-stage heart failure. The early and late period after LVAD implantation can be severely complicated. Right ventricular failure (RVF) still remains a common complication after LVAD implantation. RVF is the cause of reduced post-implant survival. We suggest that an additional temporary or permanent right ventricular assist device (RVAD) is an effective treatment for LVAD-associated RVF. In this clinical case report, we describe the medical history of a pediatric patient (14 years old) with severe heart failure (PediMACS Level 1) against a background of dilated cardiomyopathy. The patient required peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) prior to urgent LVAD (HM3) implantation. In the early post-LVAD implantation (1 POD) period, the patient presented with hemodynamic and echocardiographic events of acute RVF that was resistant to drug therapy (inotropic/vasopressor support, iNO) and required mechanical circulatory support (MCS) with a preoperatively implanted VA-ECMO. In the LVAD-associated RVF scenario, VA-ECMO as a means of total cardiac bypass is a non-physiological MCS method and, therefore, undesirable. In this clinical situation, our solution was to use a paracorporeal centrifugal blood pump for temporary right heart support. A RVAD was assembled using percutaneous cannulation in two sites and a modification of the pre-existing VA-ECMO circuit. For RVAD, we used an ECMO cannula previously installed through the femoral vein (26 F) and added a reverse venous cannula (22 F) through the right internal jugular vein into the pulmonary trunk. To facilitate the passage of the return cannula into the pulmonary artery, we used a contralateral sheath (6 F, 40 cm) and an Amplatz Super Stiff guidewire under radiological control. The oxygenator was removed from the circuit on day 2 of RVAD. Central hemodynamics (reduction in right atrial pressure (RAP) to 10 mm Hg, increase in pulmonary capillary wedge pressure (PCWP) to 14 mm Hg), as well as right ventricular (RV) and left ventricular (LV) volume characteristics all improved. These observations allowed us to optimize the performance of the implantable LVAD (increase in flow rate to 4.2 l/min or 2.1 l/min/m2). The duration of paracorporeal RVAD after LVAD implantation was 7 days with an average flow rate of 2.3 ± 0.2 l/min. Postoperative treatment in the intensive care unit (ICU) lasted for 15 days. The patient was discharged from the hospital on postoperative day 34.

Outcomes in high-risk pulmonary embolism patients undergoing FlowTriever mechanical thrombectomy: the FLAME study in perspective.

Pulmonary embolism (PE) is a common and life-threatening acute cardiovascular problem. In some patients, an abrupt increase in right ventricular (RV) afterload and impaired gas exchange result in acute RV failure, hypoperfusion, and severe hypoxemia due to V/Q mismatch. State-of-the-art management of acute PE includes early detection, risk stratification based on clinical, imaging, and biomarker criteria, and multidisciplinary decision-making regarding therapy.1,2 The European Society of Cardiology guidelines for management of PE recommend selection of therapy based on clinical severity of the presentation with class I recommendations for anticoagulation and systemic thrombolysis in patients with high-risk PE and for surgical thrombectomy in such patients in whom thrombolysis is contraindicated or has failed.3 Catheter-directed interventions for acute PE are aimed at increasing the cross-sectional area of patent pulmonary vasculature, thereby lowering resistance and alleviating V/Q mismatch.1,2 Percutaneous catheter-directed treatments are recommended as a reasonable alternative (Class IIa) in patients for whom thrombolysis is contraindicated or has failed.

Strategies in Patients with Right Ventricular Failure on Mechanical Ventilation

Right ventricular failure is a complex clinical syndrome, and is a challenge for the intensivist to diagnose in critically ill patients, more so in patients receiving mechanical ventilation. Acute RV failure is a sudden deterioration of RV function and an inability of the RV to pump adequate cardiac output to the pulmonary circulation, thereby leading to inadequate cardiac output to the systemic circulation. The most common causes of acute RV failure are acute RV myocardial infarction, massive pulmonary embolism, congenital heart diseases, and severe pulmonary arterial hypertension. Over the years, RV has been considered a passive chamber of the heart and has received less focus about the way it functions and how efficiently the RV dysfunction can be managed. The National Heart Lung and Blood Institute in 2006 convened a working group to better understand the mechanisms of right ventricular dysfunction and the various ways and means to diagnose and manage right ventricular dysfunction.

Large Animal Investigation of Cardiopulmonary Support for Acute-on-Chronic Right Ventricular Failure: Physiologic and Hemodynamic Consequences of Circuit Configuration

<h3>Purpose</h3> Right ventricular failure (RVF) is a major cause of mortality in pulmonary hypertension (PH) patients. Mechanical circulatory support holds promise for this population, but there are currently no clinical devices for long-term right ventricular (RV) support. Investigations into optimal device parameters and cannulation configurations for PH-induced RVF (PH-RVF) are needed. <h3>Methods</h3> We developed and evaluated a low-profile, ventricular assist device (VAD)-quality pump combined with a low-resistance membrane oxygenator, the Pulmonary Assist Device (PAD), for RV support in 11 sheep with chronic PH and RV hypertrophy. Four central cannulation configurations were evaluated: (1) right atrium-to-left atrium (RA-LA, N=3), (2) RA-to-pulmonary artery (RA-PA, N=3), (3) pumpless PA-to-LA (PA-LA, N=2), and (4) RA-ascending aorta (RA-Ao, N=3). Acute RVF was induced, and mechanical support was provided for up to 6 hours with blood flow rates of 1-3 L/min. Circuit, hemodynamic and echocardiographic data were collected. <h3>Results</h3> RA-LA achieved blood flow of 3 L/min within pump's operable speed, while RA-PA and RA-Ao were flow-limited due to higher circuit afterload. PA-LA could not achieve flow above 1 L/min. The oxygenator maintained a low resistance of <4 mmHg/L/min and provided oxygen delivery of 114 mL/min. RA-LA demonstrated serial RV unloading and lower inotropic dependence with increasing circuit flow. RA-Ao exhibited some RV unloading, but to a lesser extent compared to RA-LA. Meanwhile, the hemodynamic response was highly variable in RA-PA. In one trial of RA-PA, the circuit elicited severe pulmonary hemorrhage. Based on echocardiograms, only RA-LA preserved physiologic ventricular geometry. <h3>Conclusion</h3> RA-LA successfully unloads the RV at a lower pump speed, lower inotrope requirement, and improved LV filling compared to RA-Ao. RA-PA and pumpless PA-LA configurations were less viable as RV support in this study.

Acute Cholecystitis Masking Right-Sided Heart Failure: A Near-Miss Event

<h3>Introduction</h3> Pulmonary hypertension (PAH) may lead to progressive right-ventricular (RV) heart failure with symptoms of hypervolemia such as renal or hepatic congestion. We present a case of a critically ill patient presenting as sepsis from acute cholecystitis, which was later unmasked as RV failure due to uncontrolled PAH. <h3>Case Report</h3> A 67-year-old female with known PAH presented with 4 days of right upper quadrant abdominal pain and emesis. She was tachycardic and hypotensive. CT imaging showed a thick, fluid-filled gallbladder with ascites concerning for acute cholecystitis. Lab testing revealed a lactic acid of 10 and leukocytosis of 11,000. She was managed with IV antibiotics and planned for surgery, until a bedside echocardiogram showed a dilated RV and RA with severe tricuspid regurgitation. A catheterization confirmed severely elevated right heart pressures. She was started on IV treprostinil, milrinone, and diuretics with resolution of lactic acidosis and abdominal pain. <h3>Decision Making</h3> The patient's history of PAH along with evidence of hypervolemia led to suspicion of acute RV failure as the cause of cholecystitis. This led to changes in management by holding IV fluids as would otherwise be indicated in sepsis and prompting an urgent echocardiogram and heart catheterization. The diagnosis was confirmed and she was started on appropriate therapy. <h3>Summary</h3> Understanding complications of PAH and acute RV failure, which can produce symptoms similar to an acute abdominal syndrome, may prompt early appropriate interventions and prevent potentially harmful management.

Use of Isolated Right Ventricular Assist Device for Refractory Graft Failure Following a Pediatric Orthotopic Heart Transplantation

<h3>Introduction</h3> Mechanical circulatory support for isolated right ventricular (RV) failure following heart transplantation (HT) is well described in the adult literature. However, there are no similar pediatric reports . We report a case of successful use of paracorporeal CentriMag ventricular assist device as a bridge to recovery for acute RV failure following HT. <h3>Case Report</h3> This is a 12-month-old with complex congenital heart disease; single ventricle (SV), common AV valve, pulmonary atresia, heterotaxy, with dextrocardia, situs inversus and interrupted inferior vena cava with azygous continuation to a left superior vena cava. Stage 1 palliation with a ductal stent was performed in the neonatal period. She was deemed not a suitable candidate for SV palliation due to poor ventricular function as such was listed for HT. She underwent a complex HT operation including hilum-to-hilum pulmonary artery reconstruction. Intraoperative echocardiogram showed reasonable left ventricular function but poor RV function with high central venous pressure(CVP). Despite increasing inotropic support she remained hypotensive. A decision was made to place the patient on RVAD using a CentriMag device, with configuration from the right atrium to the main pulmonary artery. The patient hemodynamics improved immediately and decreased CVP. Patient was supported on RVAD for 72h before explantation. She was extubated on post op day 4 and discharged home after two weeks. At six months post HT she remains with normal graft function. <h3>Summary</h3> Acute RV dysfunction after HT is attributed to either an increase in pulmonary vascular resistance or loss of contractility in the donor heart. In this patient, a combination of pulmonary hypertension, diffuse hypoplasia of the pulmonary arteries and long donor ischemic time contributed to RV dysfunction. The present case is unique in that this patient was successfully supported with isolated RVAD, avoiding VA ECMO which is traditionally the modality of choice in such a case scenario. To the best of our knowledge, this is first case report of an infant supported on RVAD following HT. Consideration of RVAD to manage refractory primary graft failure related to RV dysfunction following HT should be considered especially in the absence of need for pulmonary or left ventricular support.

The Protek-Duo Cannula for Temporary Percutaneous Right Ventricular Support: An Early Single-Centre Experience

<h3>Purpose</h3> The Protek-Duo is a novel dual lumen cannula, designed for temporary percutaneous right ventricular support. We report our early experience with the use of this device in different clinical scenarios. <h3>Methods</h3> We reviewed all cases of Protek-Duo use at our Institution. One patient was implanted in the operating room by trans-oesophageal echocardiography (TOE) guidance and direct confirmation of the right position through the opened chest. In all the other cases, the device was positioned in the hybrid room under fluoroscopy and TOE monitoring. The Levitronix centrifugal pump was connected to the Protek-Duo to run the para-corporeal right ventricular assist device (RVAD) in each case. <h3>Results</h3> We applied the Protek-Duo cannula in 10 patients. Six were severe right ventricle primary graft dysfunctions (PGD-RV) after heart transplant (HTx). Three were cases of biventricular failure, managed through the Protek-Duo combined to a para-corporeal left ventricular assist device (LVAD). One was a severe acute RV failure after the implantation of a durable LVAD. In all the cases, the 29Fr cannula was used. There were no procedural complications at implant. All the 6 cases of PGD-RV recovered, allowing for the device weaning after 4, 12, 9, 28, 30 and 24 days; one patient died of sepsis late after the device removal. Of the three cases of BiVAD support, two, ineligible to Htx, died after 17 and 15 days of support (due to sepsis and mesenteric ischemia, respectively). The remaining patient, was successfully transplanted after 2 days. The one case of RV failure after durable LVAD implant recovered and was weaned off the support after 25 days. Overall, we recorded 3 thrombotic events (2 in the internal jugular vein and 1 in the RV; all solved by oral anticoagulation), no other device-related complications were observed. <h3>Conclusion</h3> The Protek-Duo cannula proved to be safe and effective as percutaneous RVAD in cases of PGD-RV after HTx, BiVAD support and RV failure after durable LVAD implant.

ACUTE RIGHT VENTRICULAR DYSFUNCTION FIXED IN A HEARTBEAT

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Acute right ventricular (RV) dilation is often associated with acute pulmonary embolism (PE) or right-sided myocardial ischemia. Acute RV dilation can lead to RV failure, in which the RV doesn't maintain sufficient blood flow through the pulmonary circulation. Common causes of RV failure include pulmonary arterial hypertension (PAH), COPD, and massive PE. In the ICU, pulmonary vascular disease complicated by insufficient myocardial contractility as well as derangements in excessive preload or afterload can result in changes in cardiopulmonary physiology. Determining the cause of RV decompensation and reversing it is integral in the initial management of RV failure. CASE PRESENTATION: 82-year-old female with no known medical history was admitted to medical service for sepsis secondary to cholecystitis requiring percutaneous cholecystectomy tube placement. She received IV fluids and appropriate antibiotics. On day two of hospitalization, a rapid response was called due to hypoxemia and increased work of breathing. Vital signs were afebrile, BP 88/56, HR 110, RR 26. She was placed on BIPAP and transferred to the ICU. Physical examination findings were significant for decreased breath sounds and 2+ edema in both lower extremities. Laboratory values were significant for elevated troponin 0.242 and BNP 1,000. No evidence of ischemia on EKG. CT angiography (CTA) showed bilateral pleural effusions but did not show evidence of PE. Bedside transthoracic echocardiogram (TTE) showed septal bounce and mild left atrial dilation and hypokinesis. Repeat TTE two days later showed a newly developed severely dilated RV with a severe reduction in systolic function, severely dilated right atrium and dyssynergic ventricular septal motion. Right heart cardiac catheterization confirmed elevated pulmonary artery pressures to 60-65 mmHg. Fluids were stopped, Lasix was given and sepsis was treated. TTE two days later showed marked improvement and near normalization of the RV systolic function. DISCUSSION: The patient's first TTE showed septal bounce consistent with pre-existing RV pressure overload. Acute severe RV dilation combined with hypotension likely represented an acute pulmonary hypertension crisis. The lack of a large PE on CTA ruled out thromboembolic disease for the cause of the acute dilation. RV infarct was unlikely as this would not cause elevated pulmonary artery pressures and elevated pulmonary vascular resistance. RV systolic function was restored once her sepsis was treated and fluids were stopped. It is likely that she had pre-existing primary pathology, such as chronic PAH, which was tipped over by her sepsis. CONCLUSIONS: Our patient manifested with acute RV failure in the setting of her septic physiology. Most cases of RV failure have gradual recovery; however, our case demonstrates an instance of varying RV function with significant rapid improvement in cardiac function. REFERENCE #1: Ventetuolo CE, Klinger JR. Management of acute right ventricular failure in the intensive care unit. Ann Am Thorac Soc. 2014;11(5):811-822. doi:10.1513/AnnalsATS.201312-446FR REFERENCE #2: Acute decompensated pulmonary hypertensionLaurent Savale, Jason Weatherald, Xavier Jaïs, Constance Vuillard, Athénaïs Boucly, Mitja Jevnikar, David Montani, Olaf Mercier, Gerald Simonneau, Elie Fadel, Olivier Sitbon, Marc HumbertEuropean Respiratory Review Dec 2017, 26 (146) 170092; DOI: 10.1183/16000617.0092-2017 REFERENCE #3: Matthews JC, McLaughlin V. Acute right ventricular failure in the setting of acute pulmonary embolism or chronic pulmonary hypertension: a detailed review of the pathophysiology, diagnosis, and management. Curr Cardiol Rev. 2008;4(1):49-59. doi:10.2174/157340308783565384 DISCLOSURES: No relevant relationships by Joseph Bahgat, source=Web Response No relevant relationships by Frantz Hastrup, source=Web Response

Improving Prediction of Acute Right Ventricular Failure in Patients Undergoing Left Ventricular Assist Devices Using Novel Comprehensive Eighteen-Segment Echocardiographic Strain Analysis

<h3>Purpose</h3> The complex anatomy and different contraction patterns of the different right ventricular (RV) wall segments has made it challenging to predict acute RV failure (ARVF) in patients receiving a left ventricular assist device (LVAD). We sought to improve the prediction of ARVF after LVAD by performing a comprehensive 18-segment strain (ε) analysis of the RV. <h3>Methods</h3> Prospectively enrolled LVAD recipients had a right heart catheterization and echocardiogram prior to implant. From RV-focused views (Figure 1A), 18-segment ε was performed and indexed to pulmonary arterial elastance (Ea [PV]). ARVF was defined as need for RVAD, inotropes for >14 days or pulmonary vasodilator for >48 hours post-LVAD. Logistic regression was used to identify associations between specific parameters and ARVF. <h3>Results</h3> ARVF occurred in 15 of 30 patients enrolled. Lower pulmonary artery pulsatility index (PAPi), TAPSE and basal free wall (FW) (basal anterior, lateral and posterior FW) segmental ε/Ea (PV) were significantly associated with ARVF. Indexed basal FW segmental strain provided incremental predictive value over PAPi and TAPSE (Figure 1B). <h3>Conclusion</h3> Prediction of ARVF in LVAD candidates can be improved by adding comprehensive RV segmental strain analysis to traditional echocardiographic and hemodynamics parameters.

Lung Herniation and Torsion Contributing to Persistent RV Dysfunction after Heart-Lung Transplant

<h3>Purpose</h3> Lung herniation and torsion are rare and life-threatening complications post-lung transplant, resulting in vascular compromise, airway obstruction and eventual necrosis. Timely diagnosis is imperative as delays can potentiate ischemia of the lung tissue, increasing morbidity and mortality. Few case reports of lung herniation post-dual heart-lung transplant (HLTx) have been published. We present a unique case of a HLTx complicated by retrocardiac lung herniation and torsion. <h3>Methods</h3> 50 y.o. M with bronchiectasis, cor pulmonale, and severe pulmonary HTN underwent HLTx. He was extubated to nasal canula within 24 hours, however remained vasoplegic requiring inotropic and pressor support, with TTE showing RV dysfunction. On POD 5, pressors were weaned off, however, inotropic support was still required despite normal oxygenation and chest radiograph without acute infiltrates. Further evaluation with bronchoscopy showed extrinsic, pulsating compression of right lower lobe (RLL) "fish-mouth" inlet with inability to pass bronchoscope (Figure 1A). Emergent CT chest revealing RLL torsion and retrocardiac herniation into contralateral hemithorax (Figure 1B). <h3>Results</h3> Patient taken to OR for de-torsion and herniation reduction, with intraoperative bronchoscopy confirming correct anatomical position (Figure 1C). <h3>Conclusion</h3> Acute RV failure accounts for 50% of post-operative complications and 20% of early mortality post-HLTx. Although airway complications are generally confined to the anastomosis, the heart may be compressed by adjacent structures, including a malpositioned lung lobe, and may present as cardiac dysfunction. Early recognition of unique complications, as seen in this case, is critical as vascular and airway compromise may result in irreversible lung damage. De-torsion and reduction of the herniation may allow for full recovery; however, if it fails or is unable to be performed, patients may require a lobectomy to protect the remaining viable lung tissue.

Inhaled Selective Pulmonary Vasodilators for Advanced Heart Failure Therapies

<h3>Purpose</h3> Inhaled pulmonary vasodilators (iPVD) are commonly used to lower PVR to modify the risk of acute RV failure in durable LVAD implantation or orthotopic heart transplantation (OHT). While inhaled nitric oxide (iNO) is the iPVD gold standard, inhaled epoprostenol (Veletri®) has been introduced as a cost-conscious alternative without high-grade evidence. Thus, we conducted an investigation to primarily determine if inhaled epoprostenol is equivalent to iNO in the ability to modify acute RVF after advanced heart failure therapies. <h3>Methods</h3> Our group has enrolled 232 patients (LVAD, N=100; OHT, N=132) in a triple-blinded (clinician, subject, statistician) randomized controlled trial conducted between May 2017-October 2020 (NCT03081052). Participants were grouped into strata according to key clinical prognostic features. Within each stratum, subjects were assigned either iNO or inhaled epoprostenol via 1:1 randomization. To assess equivalency between the two treatment arms for our primary outcome analysis, we will calculate absolute and relative risk estimates and corresponding confidence intervals (CI). If the CI do not contain the margin of difference (15%), then we will conclude there is sufficient evidence that the risk of the primary outcome in each treatment arm is similar. For each secondary outcome, we will construct univariable effect estimates and corresponding CI, which will allow for assessment of difference between treatment arms. In the case that patients have switched to the other treatment arm, we will perform an intent-to-treat (ITT) analysis without reclassifying treatment assignment. To verify ITT results, we will perform a per-protocol analysis. <h3>Endpoints</h3> <b>Primary.</b>LVAD: Moderate or Severe RVF (defined by INTERMACS, up to 21-days after surgery); OHT: PGD-RV treated with RVAD <i>or</i> VA-ECMO, up to 30-days after surgery. <b>Secondary.</b> Duration of postoperative mechanical ventilation, iPVD duration/cost, ICU and hospital lengths-of-stay, postoperative acute kidney injury, and 30-day mortality.

The effect of transfusion of blood products on ventricular assist device support outcomes.

AimsPerioperative blood transfusions are common among patients undergoing left ventricular assist device (LVAD) implantation. The association between blood product transfusion at the time of LVAD implantation and mortality has not been described.Methods and resultsThis was a retrospective cohort study of all patients who underwent continuous flow LVAD implantation at a single, large, tertiary care, academic centre, from 2008 to 2014. We assessed used of packed red blood cells (pRBCs), platelets, and fresh frozen plasma (FFP). Outcomes of interest included all‐cause mortality and acute right ventricular (RV) failure. Standard regression techniques were used to examine the association between blood product exposure and outcomes of interest. A total of 170 patients were included in this study (mean age: 56.5 ± 15.5 years, 79.4% men). Over a median follow‐up period of 11.2 months, for every unit of pRBC transfused, the hazard for mortality increased by 4% [hazard ratio (HR) 1.04; 95% CI 1.02–1.07] and odds for acute RV failure increased by 10% (odds ratio 1.10; 95% CI 1.05–1.16). This association persisted for other blood products including platelets (HR for mortality per unit 1.20; 95% CI 1.08–1.32) and FFP (HR for mortality per unit 1.08; 95% CI 1.04–1.12). The most significant predictor of perioperative blood product exposure was a lower pre‐implant haemoglobin.ConclusionsPerioperative blood transfusions among patients undergoing LVAD implantation were associated with a higher risk for all‐cause mortality and acute RV failure. Of all blood products, FFP use was associated with worst outcomes. Future studies are needed to evaluate whether pre‐implant interventions, such as intravenous iron supplementation, will improve the outcomes of LVAD candidates by decreasing need for transfusions.

HEMOPTYSIS AND PREGNANCY: A CASE OF UNCORRECTED ATRIAL SEPTAL DEFECT AND PULMONARY HYPERTENSION

Uncorrected atrial septal defect (ASD) can lead to severe pulmonary hypertension (pHTN) and shunt reversal. Pregnancy in a patient with pHTN carries high fetal and maternal mortality risk. Even after successful delivery, acute RV failure and paradoxical embolus occur. As such, current guidelines

Baseline pulmonary hypertension in heart transplant recipients: 9 years of experience at Almazov National Medical Research Centre

Objective: to assess the impact of baseline pulmonary hypertension (PH) on early and long-term outcomes following heart transplantation (HT). Materials and methods. From January 2010 to December 2018, 112 HTs were carried out. Based on right heart catheterization results, all recipients were divided into 2 groups: Group 1 with PH (n = 76; mean pulmonary arterial pressure (mPAP) ≥25 mm Hg), Group 2 – without PH (n = 36; MPAP &lt;25 mm Hg). The average age of Group 1 patients was 46.4 ± 14.9 years, baseline pulmonary vascular resistance (PVR) was 3.5 ± 1.5 Wood units, PVR after reversion test (nitric oxide – 80 ppm, iloprost 20 μg) – 2.8 ± 1.0 Wood units, systolic PAP (sPAP) – 50.1 ± 13.4 mm Hg. The average age in Group 2 was 47.3 ± 12.2 years, baseline PVR – 2.1 ± 0.8 Wood units, sPAP – 27.4 ± 5.3 mm Hg. The dynamics in indicators of early postoperative period (duration of mechanical ventilatory support, use of vasodilators and inotropic support and the length of stay in intensive care unit (ICU), 30-day mortality) and long-term post-HT echocardiography results were assessed. Results. Due to acute right-ventricular failure (RVF) developing after heart transplantation, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was done in 8 patients (11%) from Group 1 and one patient (3%) from Group 2. Presence of PH did not affect duration of mechanical ventilatory support, inotropic support, and length of stay in ICU. Levosimendan therapy in the early postoperative period was more often performed in Group 1 (n = 29) than in Group 2 (n = 6) (p = 0.048). Nitric oxide inhalation was also more often administered in Group 1 (n = 54); Group 2 (n = 7), (p = 0.003). Sildenafil therapy after HT was comparable in both groups Group 1 (n = 25); Group 2 (n = 6), (p = 0.048). In early post-HT stages, 14 patients died, 30-day mortality was comparable in both groups (p = 0.12). Six months after HT, no differences were found in the sPAP (p = 0.21) and PVR (p = 0.07) levels. Conclusion. Patients with baseline PH after HT have a more severe early postoperative period, including a higher RVF incidence, with the need for ECMO implantation. A PVR level &gt;3.5 Wood units is not a threshold for HT. Patients with baseline PVR &gt;3.5 Wood units following HT show comparable results with patients without baseline PH. This allows such patients (baseline PVR &gt;3.5 Wood units) to be considered for inclusion in the heart transplant waiting list. In addition, 30-day mortality and duration of mechanical ventilatory support after HT in patients with and without baseline PH did not differ. Regardless of the baseline level of sPAP and PVR, all patients showed improvement in these parameters after HT. Six months after HT, no differences were found in sPAP and PVR levels in the patients, regardless of whether there was baseline PH or not.

Pulmonary artery cannulation to enhance extracorporeal membrane oxygenation management in acute cardiac failure.

Pulmonary artery (PA) cannulation during peripheral venoarterial extracorporeal membrane oxygenation (ECMO) has been shown to be effective either for indirect left ventricular (LV) unloading or to allow right ventricular (RV) bypass with associated gas-exchange support in case of acute RV with respiratory failure. This case series reports the results of such peculiar ECMO configurations with PA cannulation in different clinical conditions. All consecutive patients receiving PA cannulation (direct or percutaneous) from January 2015 to September 2018 in 3 institutions were retrospectively reviewed. Isolated LV unloading or RV support, as well as dynamic support including initial drainage followed by perfusion through the PA cannula, was used as part of the ECMO configuration according to the type of patient and the patient's haemodynamic/functional needs. Fifteen patients (8 men, age range 45-73 years, EuroSCORE log range 14.45-91.60%) affected by acute LV, RV or biventricular failure of various aetiologies, were supported by this ECMO mode. Percutaneous PA cannulation was performed in 10 patients and direct PA cannulation, in 5 cases. Dynamic ECMO management (initially draining and then perfusing through the PA cannula) was carried out in 6 patients. Mean ECMO duration was 9.1 days (range 6-17 days). One patient exhibited pericardial fluid during the implant of a PA cannula (no lesion found when the chest was opened), and weaning from temporary circulatory support was achieved in 14 patients (1 who received a transplant). Three patients (20%) died in-hospital, and 12 patients were successfully discharged without major complications. Effective indirect LV unloading in peripheral venoarterial ECMO as well as isolated RV support can be achieved by PA cannulation. Such an ECMO configuration may allow the counteraction of common venoarterial ECMO shortcomings or allow dynamic/adjustable management of ECMO according to specific ventricular dysfunction and haemodynamic needs. Percutaneous PA cannulation was shown to be safe and feasible without major complications. Additional investigation is needed to confirm the safety and efficacy of such an ECMO configuration and management in a larger patient population.