Biventricular Failure Research Articles

Severe post-COVID virus positive lymphocytic myocarditis with infective endocarditis: Сhallenges of diagnosis and treatment

A 39-year-old patient with bicuspid aortic valve underwent COVID-19 in August 2020. In September, he developed fever, dyspnea, arthralgias, hemorrhagic rash, followed by biventricular heart failure (December 2020).

(826) Dual VADs to Dual Organs: Successful Bridge to Heart and Kidney Transplantation with 2 HeartMate 3 LVADs in Biventricular Failure

(826) Dual VADs to Dual Organs: Successful Bridge to Heart and Kidney Transplantation with 2 HeartMate 3 LVADs in Biventricular Failure

(843) Change in NT-ProBNP to Predict Development of Right, Left, and Biventricular Heart Failure in Heartmate 3 LVAD Patients

(843) Change in NT-ProBNP to Predict Development of Right, Left, and Biventricular Heart Failure in Heartmate 3 LVAD Patients

A tale of 2 conversions: Dichotomous decision in the spectrum of Shone syndrome is still a dilemma

A tale of 2 conversions: Dichotomous decision in the spectrum of Shone syndrome is still a dilemma

Molecular basis of amyloid deposition in myocardium: not only ATTR and AL. Case report

Alterations in the proteostasis network and accumulation of misfolded protein aggregates — is one of the new pathogenesis concepts of chronic heart failure. We hypothesis in addition to well-known transthyretin (ATTR) and AL-amyloidosis some patients may represent amyloid lesion in myocardium came from undescribed amyloidogenic precursors due to misfolding of myocardial structural proteins.Here, we report on the case of patient with hypertrophic and restrictive phenotype of cardiomyopathy, biventricular heart failure, considered for heart transplant, and excluded known types of amyloidosis. Genetic testing revealed extended deletion in the gene of giant protein titin (TTN).We present with the use of bioinformatic analysis and molecular modeling how this mutation could lead to unfolding of corresponding protein and open its amyloidogenic motifs for intermolecular interactions, therefore, provide amyloidogenic ability. This data enables in more detail to decipher the pathogenesis of chronic heart failure on the background of cardiomyopathy, planning further studies for development of personalized risk profiling in different types of amyloidosis and elaborate more personalized treatment approach for such patients in the future.

Biventricular circulatory support using single-device and dual-device configurations: Initial pump characterization in simulated heart failure model.

Severe biventricular heart failure (BHF) can be remedied using a biventricular assist device (BVAD). Two devices are currently in development: a universal ventricular assist device (UVAD), which will be able to assist either the left, right, or both ventricles, and a continuous-flow total artificial heart (CFTAH), which replaces the entire heart. In this study, the in vitro hemodynamic performances of two UVADs are compared to a CFTAH acting as a BVAD. For this experiment, a biventricular mock circulatory loop utilizes two pneumatic pumps (Abiomed AB5000™, Danvers, MA, USA), in conjunction with a dual-output driver, to create heart failure (HF) conditions (left, LHF; right, RHF; biventricular, BHF). Systolic BHF for four different situations were replicated. In each situation, CFTAH and UVAD devices were installed and operated at two distinct speeds, and cannulations for ventricular and atrial connections were evaluated. Both CFTAH and UVAD setups achieved our recommended hemodynamic criteria. The dual-UVAD arrangement yielded a better atrial balance to alleviate LHF and RHF. For moderate and severe BHF scenarios, CFTAH and dual UVADs both created excellent atrial pressure balance. Conversely, when CFTAH was atrial cannulated for LHF and RHF, the needed atrial pressure balance was not met. Comprehensive in vitro testing of two different BVAD setups exhibited self-regulation and exceptional pump performance for both (single- and dual-device) BHF support scenarios. For treating moderate and severe BHF, UVAD and CFTAH both functioned well with respect to atrial pressure regulation and cardiac output. Though, the dual-UVAD setup yielded a better atrial pressure balance in all BHF testing scenarios.

Successful support of biventricular heart failure in an adult patient by the Berlin Heart EXCOR system as a bridge to transplant: literature review.

Right heart failure is ahuge challenge in left ventricular assist device therapy and its occurrence is associated with increased mortality and morbidity. Other options include the use od temporary right ventricular assist device, use of two continous flow biventricular assist devices, use of total artificial heart and the use of paracorporeal biventricular assist devices.In this report we described the successful use of the paracorporeal pulsatile Berlin Heart EXCOR system as abridge to transplant in a62 years old patient with end-stage biventricular heart failure (Tab. 1, Fig. 3, Ref. 22). Keywords: biventricular heart failure, mechanical circulatory support, biventricular assist device, Berlin Heart EXCOR system, heart transplantation.

Effects of Low-Dose Tadalafil in a Patient with Biventricular Heart Failure: A Case Report.

Phosphodiesterase type 5 (PDE5) inhibitors such as tadalafil, can improve cardiac output by increasing left ventricular preload; however, there are concerns that this can increase the risk of heart failure due to pulmonary congestion in patients with elevated left ventricular end-diastolic pressure. We encountered a case in which low dose tadalafil improved the hemodynamics of a 66-year-old male patient with dilated cardiomyopathy (DCM) with congestion and low cardiac output due to biventricular dysfunction. The patient received a cardiac resynchronization therapy defibrillator (CRT-D) and appropriate medical therapy for heart failure. During a hemodynamic evaluation after heart failure symptoms were alleviated, we attempted to increase the dose of renin-angiotensin-aldosterone system (RAAS) inhibitors, which contribute to low cardiac output, hypotension, and worsening of renal function. However, the administration of a low dose of tadalafil for the patient's benign prostatic hyperplasia allowed for the increase in the dose of RAAS inhibitors and markedly improved his subjective symptoms and hemodynamics. Because of the biventricular dysfunction in severe cases, we often experience further promotion of low cardiac output by standard treatments such as RAAS inhibitors, in which low doses of PDE5 inhibitors may be effective in maintaining biventricular linkage. PDE5 inhibitors may be effective in patients, who are not able to increase the dose of RAAS inhibitors due to low cardiac output.

Staging Heart Failure Patients With Secondary Mitral Regurgitation Undergoing Transcatheter Edge-to-Edge Repair

BackgroundSecondary mitral regurgitation (SMR) is a progressive disease with characteristic pathophysiological changes that may influence prognosis. Although the staging of SMR patients suffering from heart failure with reduced ejection fraction (HFrEF) according to extramitral cardiac involvement has prognostic value in medically treated patients, such data are so far lacking for edge-to-edge mitral valve repair (M-TEER). ObjectivesThis study sought to classify M-TEER patients into disease stages based on the phenotype of extramitral cardiac involvement and to assess its impact on symptomatic and survival outcomes. MethodsBased on echocardiographic and clinical assessment, patients were assigned to 1 of the following HFrEF-SMR groups: left ventricular involvement (Stage 1), left atrial involvement (Stage 2), right ventricular volume/pressure overload (Stage 3), or biventricular failure (Stage 4). A Cox regression model was implemented to investigate the impact of HFrEF-SMR stages on 2-year all-cause mortality. The symptomatic outcome was assessed with New York Heart Association functional class at follow-up. ResultsAmong a total of 849 eligible patients who underwent M-TEER for relevant SMR from 2008 until 2019, 9.5% (n = 81) presented with left ventricular involvement, 46% (n = 393) with left atrial involvement, 15% (n = 129) with right ventricular pressure/volume overload, and 29% (n = 246) with biventricular failure. An increase in HFrEF-SMR stage was associated with increased 2-year all-cause mortality after M-TEER (HR: 1.39; CI: 1.23-1.58; P < 0.01). Furthermore, higher HFrEF-SMR stages were associated with significantly less symptomatic improvement at follow-up. ConclusionsThe classification of M-TEER patients into HFrEF-SMR stages according to extramitral cardiac involvement provides prognostic value in terms of postinterventional survival and symptomatic improvement.

1244: CAN ADMINISTRATION OF HIGH-DOSE HYDROXOCOBALAMIN IMPROVE OUTCOMES IN REFRACTORY SEPTIC SHOCK?

Introduction: Multiple high dose vasopressors are often required to sustain life in critically ill patients but are unfortunately associated with high mortality (>50%) and morbidity. This case discusses the potential benefit in adding high dose IV hydroxocobalamin (B12) therapy (5g) to potentially reduce the use of additional vasopressors and their impact on morbidity and mortality. Description: A 72-year-old immunocompromised man with history of multiple myeloma, refractory to multiple lines of therapy, prior CAR-T treatment with now stable disease was found down, covered in feces. He was admitted to the medical ICU for severe septic shock secondary to pseudomonas bacteremia. The patient progressed to Multiorgan failure requiring mechanical ventilation, broad spectrum antibiotics, and multiple vasopressors at maximum doses. Echocardiogram (echo) showed biventricular heart failure with ejection fraction (EF) reduced from 64% 4 months prior to 25%. The bronchoalveolar lavage sample grew Pseudomonas aeruginosa, and antibiotics were adjusted. He was requiring norepinephrine (NE) at 0.3 mcg/kg/min, vasopressin (vaso) at 0.04 units/min, epinephrine (epi) to 0.3 mcg/kg/min, angiotensin II (ATII) between 10-40 ng/kg/min, and dobutamine (dobut) as high as 12.5 mcg/kg/min for 47 hours before B12 administration. The patient remained hypotensive (MAP < 65 mmHg) with maximal vasopressors. The left hand become cold and discolored, his legs and abdomen became severely mottled. Due to lack of response to therapy a trial of 5g B12 was given. There was improvement in the patient’s blood pressure. NE and ATII were stopped within 24 hours, Epi and vaso stopped within 96 hours, and dobut was weaned gradually. He was extubated on day 12. EF improved to 60% with normal right ventricular function on day 14. The skin gradually returned to normal. The left-hand fingers appeared better perfused with only the tip remaining discolored. Discussion: Bacterial endotoxins released in sepsis induce nitric oxide synthase, activating cGMP, which causes subsequent smooth muscle inhibition and vasodilation. B12 scavenges nitric oxide decreasing vasodilation. Use of B12 as an adjuvant to traditional vasopressor therapy could help reduce morbidity and mortality in septic shock by reducing overall dose/duration of vasopressors.

Experience With SynCardia Total Artificial Heart as a Bridge to Transplantation in 100 Patients

BackgroundThe SynCardia temporary total artificial heart (TAH-t) is an effective bridge to transplantation for patients with severe biventricular failure. However, granular single-center data from high-volume centers are lacking. We report our experience with the first 100 TAH-t recipients. MethodsA prospective institutional database was used to identify 100 patients who underwent 101 TAH-t implantations between 2012 and 2022. Patients were stratified and compared according to Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 1 vs 2 or greater. Median follow-up on device support was 94 days (interquartile range, 33-276), and median follow-up after transplantation was 4.6 years (interquartile range, 2.1-6.0). ResultsOverall, 61 patients (61%) were successfully bridged to transplantation and 39 (39%) died on TAH-t support. Successful bridge rates between INTERMACS profile 1 and INTERMACS profile 2 or greater patients were similar (55.6% [95% CI, 40.4%-68.3%] vs 67.4% [95% CI, 50.5%-79.6%], respectively; P = .50). The most common adverse events (rates per 100 patient-months) on TAH-t support included infection (15.8), ischemic stroke (4.6), reoperation for mediastinal bleeding (3.5), and gastrointestinal bleeding requiring intervention (4.3). The most common cause of death on TAH-t support was multisystem organ failure (n = 20, 52.6%). Thirty-day survival after transplantation was 96.7%; survival at 6 months, 1 year, and 5 years after transplantation was 95.1% (95% CI, 85.4%-98.4%), 86.6% (95% CI, 74.9%-93.0%), and 77.5% (95% CI, 64.2%-86.3%), respectively. ConclusionsAcceptable outcomes can be achieved in the highest acuity patients using the TAH-t as a bridge to heart transplantation.

ECHOCARDIOGRAPHIC CHARACTERISTICS OF COVID 19 PATIENTS - A STUDY FROM DISTRICT SUPERSPECIALITY HOSPITAL IN EASTERN INDIA

Introduction: Coronavirus disease 2019 (COVID-19) has emerged as a major cause of morbidity and mortality that is placing unprecedented pressure on healthcare services across the world. Echocardiography is well placed to help further this understanding, being inexpensive, portable, and widely accessible. To describe the cardiac abnormalities in patie Aims: nts with COVID-19 and identify the characteristics of patients who would benet most from echocardiography In our study, out of 1060 patients, most of the 64 pati Materials And Method: Result: ents were 53–73 years of age in Abnormal scan and 60 patients were 51–69 years of age in Normal scan. Age was not signicantly associated with echocardiography (p=0.7194). In our study, majority number of patients had severe symptom severity in Abnormal scan [340 (52%)] compared to normal scan [285 (55%)] and it was statistically signicant (p&lt;0.0001). In our study, 118 patients had Mild Left ventricular abnormality, 87 patients had Moderate Left ventricular abnormality,59 patients had severe Left ventricular abnormality,67 patients had dilated Left ventricular abnormality,37 patients had New MI ,36 patients had Myocarditis and 18 patients had Takotsubo which was statistically signicant (p&lt; .00001). We observed that, most of the patients had Elevated PAP right ventricular abnormality though it was statistically signicant (p&lt; .00001). It was found that, most of the 137 patients had Mild or Moderate Biventricular Failure and it was was statistically signicant (p&lt; .00001). Cardiac abnormalities were Conclusion: observed in half of all COVID-19 patients undergoing echocardiography. Abnormalities were often unheralded or severe, and imaging changed management in one-third of patients.

Arterio-venous fistula causing acute right heart failure: A rare complication of veno-arterial extracorporeal membrane oxygenation.

Introduction: Vascular complications are a major issue in V-A ECMO and can affect long term outcome. Among these, Artero-Venous (AV) fistulas may lead to right heart failure.Case History: A 73-years patient supported with V-A ECMO for post-cardiotomy biventricular failure developed right heart failure after V-A ECMO decannulation, requiring V-A ECMO recannulation. The presence of an AV femoral fistula was incidentally revealed during femoral vein cannulation, from which oxygenated blood was unexpectedly drawn. The angiographic assessment confirmed the presence of a fistula between superficial femoral artery and vein, at the site of the first venous ECMO cannulation. This was caused by the venous cannula that inadvertently passed across the artery and created an AV fistula that was opened by the venous cannula removal. The exclusion of the endovascular fistula allowed the right heart failure resolution.Conclusions: In the presence of right heart failure after recent vascular manipulation, AV fistula should be ruled out.

Review of devices and clinical need for non-blood contacting mechanical circulatory support

LVADs have been in clinical use for a half-century and have advanced through at least 3 generations resulting in compact, durable, and powerful pumps that can deliver blood flow that exceeds the needs of the body at rest. In so doing, these devices have become the best alternative to transplant for patients with end-stage heart failure. That said, the blood contacting interface of these pumps is likely the cause of complications and contraindications that persist with successive generations. Patients with elevated risk for side effects or patients with biventricular failure and other conditions represent the 25% of patients that are not candidates for LVAD therapy. Such patients represent the clinical need for non-blood contacting mechanical circulatory support. The clinical use of direct cardiac compression devices is limited, and there are no devices available for human use. Technological challenges remain, yet these devices continue to be developed and tested in animal models of heart failure.

Abstract 12272: Pericardial Decompression Syndrome Following Low Volume Pericardiocentesis for Malignant Cardiac Tamponade

Introduction: Cardiac tamponade is a life-threatening condition requiring emergent intervention. Pericardial decompression syndrome (PDS) is a rare complication that presents as acute ventricular dysfunction following pericardiocentesis with a mortality rate up to 29%. In this case, we present a patient with PDS who developed cardiogenic shock following pericardiocentesis for cardiac tamponade. Clinical course: A 58-year-old female with no significant cardiac history presented with chest pain and dyspnea. Computed topography revealed a mediastinal mass and large pericardial effusion. Transthoracic echocardiogram (TTE) demonstrated the effusion with tamponade physiology. Left ventricular (LV) systolic function was preserved at this time. A total of 450ml of serosanguinous fluid was removed by pericardiocentesis, with minimal residual volume around the RV and a large effusion remaining around the LV. Repeat TTE 14 hours later revealed severe global hypokinesis and biventricular failure with an LV EF of 15%. The patient was started on inotropic therapy and transferred to our tertiary care center. Continuous diuresis and vasopressor therapy were initiated. Once stable, the patient was taken for pericardial window with further removal of 600ml of fluid. Subsequent TTE demonstrated recovery of LV systolic function to 47%. Discussion: Our patient developed cardiogenic shock secondary to biventricular heart failure following pericardiocentesis. This presentation is concerning for pericardial decompression syndrome. While the exact mechanism of PDS is not known, the current hypothesis postulates that drainage of fluid compressing the RV leads to a sudden increase in venous return. This abrupt change causes septal bowing and decreased LV systolic function. Some sources recommend draining pericardial fluid in smaller quantities; however, PDS may still occur at smaller volumes as was seen in our patient. PDS is a rare but life-threatening complication that requires vigilance post-pericardiocentesis regardless of volume removed.

Abstract 334: Cardiogenic Shock In Heart Transplant Candidates - Improved Outcome With Impella 5.5

Background: Heart transplant (HTX) candidates often develop cardiogenic shock (CS) and require mechanical circulatory support (MCS). UNOS criteria prioritize temporary MCS over durable left ventricular assist devices (LVADs). Extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pump are associated with poor outcome. In early 2020, we transitioned to using axillary Impella 5.5 in CS patients with both isolated LV or biventricular failure as bridge to HTX. This reports our two-year experience. Methods: We performed a retrospective single center chart review. 19 patients treated with Impella 5.5 as bridge to HTX were identified. UNOS criteria were used to classify CS. If inotropes and diuresis failed to resolve CS, Impella 5.5 was placed via a 10 mm graft sewn to the axillary artery. Key endpoints were survival to transplant without disabling stroke, 30-day and 1-year post-HTX survival. Results: Mean age 55 yrs, 89% male, mean Impella support 19 days (2 - 71, total 369). 58% biventricular failure with at least moderate right ventricular dysfunction (RVD). RVD was managed medically, no RV assist device or ECMO was needed. Transient elevation (&gt;40 mg/dl) of free plasma hemoglobin occurred in 42% but resolved with device repositioning and/or fluids. No renal replacement therapy was required. No serious infectious, vascular or bleeding complication occurred. There was no device malfunction, one pump was replaced due to an exposed wire after 22 days of support. 100% of patients were able to ambulate prior to HTX. Overall survival was 100%. 89% patients were successfully bridged to HTX without major morbidity. Two cases received durable LVAD. One developed non-disabling ischemic stroke on day 16 of Impella support. One elected LVAD as destination therapy after 71 days of support. Stroke free survival during Impella support was 95%. There were no disabling strokes. Post-transplant 30-day survival was 100% (n=17). 1-year post-HTX survival data was 100% (n=10). Conclusion: Impella 5.5 successfully restores hemodynamics in CS in HTX eligible patients with both isolated LV and biventricular failure. RVD in this situation can be managed medically. With this strategy, patients are able to ambulate prior to HTX and survival after HTX exceeds national average.

Abstract 13632: The Optimization of Mechanical Circulatory Support Device Combination Considering Ventricular Load in Biventricular Failure Condition: A Simulation Study

Backgrounds: Recently, the combination of Impella, a percutaneous transvalvular left ventricular assist device, and veno-arterial extracorporeal membrane oxygenation (ECMO) have improved the survival rate of cardiogenic shock by its powerful hemodynamic support effect. Meanwhile, the optimal flow control of those devices remains unclear, especially in biventricular failure (BVF). In this study, we established the mathmatical cardiovasular simulation model, and evaluated how the combination therapy impacts both right (RV) and left (LV) ventricular loading. Methods: We used SimulinkⓇ (Mathworks, Inc.) for the simulation. Both the systemic and pulmonary circulation were modeled by using 5-element resistance-capacitance net-work. Four cardiac chambers were represented by time-varying elastance with unidirectional valves (Fig. 1). In LV dysfunction (LV end-systolic elastace was set at low level: 0.4 mmHg/ml), we compared the changes of right (RAP) and left (LAP) atrial pressure, as the marker of ventricular loading, under various RV function and Impella and ECMO flows. Results: Impella slightly increased RAP and reduced LAP regardless of RV systolic function (Fig. 2). In high pulmonary vascular resistance (PVR), the increase of Impella flow augumented RAP, while Impella could not be up-titrated more than 2.8 L/min due to LV suction (Fig. 3). In BVF with high PVR, ECMO decreased RAP and increased LAP in each Impella flow (Fig. 4). Higher ECMO and Impella flows rendered LV extremely small, induced suction, and increased RV preload and RAP. Conclusion: PVR is the major determinant of stable Impella support without inducing RV loading and LV suction. In BVF with high PVR, ECMO reduced RV loading, while decreased LV filling and induced LV suction by Impella. The preemptive simulation study for an individual patient may help the optimal use of mechanical circulatory support device to maximize RV and LV unloading with improving hemodynamics.

Abstract 14332: Syncope, Storm, and Shock: Fulminant Myocarditis

A 46-year-old female with prediabetes and recent hysterectomy three weeks prior presented to the hospital for syncope. Patient reported no chest pain or dyspnea but complained of intermittent palpitations. The patient developed runs of non-sustained ventricular tachycardia which quickly escalated into incessant ventricular tachycardia (VT). Unresponsive to maximal medical therapy, the patient was cardioverted, intubated and sedated. Electrocardiogram was obtained which showed ST segment elevation in V1 and V2 without reciprocal changes. Bedside point-of-care ultrasound was negative for wall motion abnormalities. Laboratory results were significant for normal electrolytes, elevated troponins peaking at 7.14 ng/mL the following morning, and lactic acid of 3.2 mmol/L. Patient was initiated on vasopressor and ionotropic support for suspected shock. Left heart catheterization was negative for obstructive coronary artery disease. Right heart catheterization revealed mild pulmonary hypertension and biventricular failure. Formal echocardiogram revealed mid-range ejection fraction with a small pericardial effusion. The patient’s clinical status was deteriorating and revealed multiorgan failure. In conjunction with advanced heart failure and mechanical circulatory support teams, veno-arterial extracorporeal membrane oxygenation was initiated with subsequent implantation of intra-aortic balloon pump. High-dose steroids were given while awaiting transfer to a quaternary center. The patient is currently being evaluated for endomyocardial biopsy and evaluation of left ventricular assist device or heart transplantation due to fulminant myocarditis (FM). FM requires early recognition, intensive support, and further investigation for optimal management.

Abstract 15813: Comparative Case Series of Biventricular Support Between Heartmate-3 Ventricular Assist Devices and the Total Artificial Heart: A Single-Center Experience

Introduction: Currently, only the Syncardia Total Artificial Heart (TAH) is approved for biventricular support as a bridge-to-transplant (BTT). The off-label use of continuous flow ventricular assist devices (VAD) in a biventricular configuration (BiVAD) has been used with variable results, emphasizing the need for patient selection. We report our single-center BiVAD experience in patients supported with two HeartMate-3 (HM-3) VADs in a biventricular configuration in comparison with TAH support. Methods: All patients receiving durable biventricular mechanical support at The Mount Sinai Hospital (New York, New York) were considered. Baseline clinical, echocardiographic, hemodynamic and outcome data were extracted. Outcomes of interest were postoperative survival and adverse events, and compared using non-parametric statistics. Successful BTT and post-transplant survival were descriptively evaluated. Results: From November 2018 through May 2022, a total of 6 (37.5%) patients received two HM-3 VAD pumps in a BiVAD configuration and 10 (62.5%) patients received a TAH. Overall, TAH patients had significantly higher median INTERMACS profiles (p &lt; 0.05) at baseline compared to those on HM-3 BiVAD support but lower 30-day and 6-month survival and with a significantly higher rate of renal failure (Table 1). However, survival declined to the same rate at 1-year with both forms of support and was largely due to extracardiac adverse events related to underlying comorbidities (particularly, CKD/ESRD and diabetes, p &lt; 0.05). Successful BTT has thus far been achieved in 2 (33%) HM-3 BiVAD compared to 5 (50%) TAH patients, and had similar post-transplant survival at 1-year. Conclusions: HM-3 BiVAD demonstrated lower short-term and similar long-term mortality compared to TAH support among patients in extremis. However, larger studies are needed to optimize patient selection and pursuit of mechanical support in biventricular failure.

Abstract 9777: Percutaneous Ambulatory Biventricular Support With Protekduo and Impella: A Community Hospital Experience

Introduction: With the advent of percutaneous MCS devices, like the Abiomed ® Impella TM LVAD and Livanova ® ProtekDuo TM RVAD, patients with biventricular failure necessitating ECLS can be transitioned to a fully ambulatory femoral-free BIVAD configuration. Case: A 60-year-old man presented with atrial fibrillation. He underwent TTE revealing EF &lt;20%. After cardiac cath ruled out ischemic cause, he underwent TEE with plan for cardioversion. Upon induction, he suffered a PEA arrest and VA- ECMO support promptly ensued, per ECLS protocol, with b/l femoral cannulation. An Impella TM CP LVAD was also inserted to provide unloading and further support. After 2-days with b/l groin ECMO cannulation with femoral percutaneous LVAD, the patient awoke, displaying adequate urine output and following of basic commands. Transition was made from femoro-femoral cannulation to percutaneous right-IJ ProtekDuo TM RVAD attached to a Quadrox-i ® oxygenator for ECMO support, along with transition of femoral Impella TM CP to a robust axillary Impella TM 5.5 LVAD (Figure). This configuration decannulated the groins, permitting the patient to work with physical therapy. Discussion: Transition to groin-free configuration with percutaneous BIVAD apparatus implementing the ProtekDuo TM RVAD with Impella TM 5.0/5.5 axillary LVAD has only been reported at a large cardiovascular institute in Germany. That case series highlighted how percutaneous ambulatory BIVAD allowed for rapid extubation, early mobilization, and minimal complications 1 . Herein, we demonstrated the first presumed community-hospital experience with this underreported mechanical circulatory support combination promoting a pathway to rehabilitation and eventual transplantation. Conclusion: This report showcases the feasibility of adapting percutaneous ambulatory BIVAD with a combined ProtekDuo TM /Impella TM groin-free apparatus in the community-hospital setting.