Support For Right Ventricular Failure Research Articles

Use of percutaneous mechanical circulatory support for right ventricular failure.

Utilization of right ventricular mechanical circulatory support (RV-MCS) devices has been limited by a lack of recognition of RV failure as well as a lack of availability and experience with RV-MCS. We report a single-center experience with the use of percutaneous RV-MCS and report predictors of adverse outcomes. This was a single-center retrospective cohort study. Data from consecutive patients who received RV-MCS for any indication between June 2015 and January 2022 were included. Data on baseline comorbidities, hemodynamics, and laboratory values were collected. The primary outcome was in-hospital mortality analyzed as a logistic outcome in a multivariable model. These variables were further ranked by their predictive value. Among 58 consecutive patients enrolled, the median age was 66 years, 31% were female and 53% were white. The majority of the patients (48%) were hospitalized for acute on chronic heart failure. The majority of the patients were SCAI SHOCK Stage D (67%) and 34 (64%) patients had MCS placed within 24 h of the onset of shock. Before placement of RV-MCS, median central venous pressure (CVP) and RV stroke work index were 20 mmHg and 8.9 g m/m2, respectively. Median serum lactate was 3.5 (1.6, 6.2) mmol/L. Impella RP was implanted in 50% and ProtekDuo in the remaining 50%. Left ventricular MCS was concomitantly used in 66% of patients. Twenty-eight patients (48.3%) died. In these patients, median serum lactate was significantly higher (4.1 [2.3, 13.0] vs. 2.2 [1.4, 4.0] mmol/L, p = 0.007) and a trend toward higher median CVP (24 [18, 31] vs. 19 [14, 24] mmHg, p = 0.052). In the multivariable logistic model, both serum lactate and CVP before RV-MCS placement were independent predictors of in-hospital mortality. Serum lactate had the highest predictive value. In our real-world cohort, 52% of patients treated with RV-MCS survived their index hospitalization. Serum lactate at presentation and CVP were the strongest predictors of in-hospital mortality.

B-3 | An Updated Assessment of Impella RP Adverse Events as Reported in Manufacturer and User Facility Device Experience (MAUDE) Database

Mechanical circulatory support devices have become essential tools in the management of refractory cardiogenic shock. Impella RP® (Abiomed, Danvers, MA) is an FDA-approved device that provides minimally invasive support for right ventricular failure. As recognition of cardiogenic shock becomes more prevalent, there is an expanded use of circulatory support devices such as the Impella RP®, necessitating a continued evaluation of complications related to its use.

Percutaneous venopulmonary artery extracorporeal membrane oxygenation for right heart failure after left ventricular assist device insertion.

Right ventricular failure after left ventricular assist device (LVAD) insertion is associated with significant mortality and morbidity. Mechanical support options include right ventricular assist devices, venoarterial extracorporeal membrane oxygenation (ECMO) and venopulmonary artery ECMO, the latter often involving central cannulation. We sought to evaluate the feasibility and early outcomes of a truly percutaneous venopulmonary artery (pVPA) ECMO strategy, with the potential advantage of bedside removal once weaned. Data from a single tertiary centre were reviewed retrospectively from January 2014 to January 2019. During this time, 54 patients underwent LVAD insertion, with 19 requiring mechanical support for right ventricular failure. Among them, 10 patients received pVPA ECMO. Implantation of the pVPA ECMO was performed under transoesophageal echocardiography and fluoroscopy guidance, with an inflow cannula placed in the right atrium via the right femoral vein and an outflow cannula placed in the left pulmonary artery (PA) via the right internal jugular vein. Cannula insertion was 100% successful with no need for repositioning. Eight patients (80%) were able to be successfully weaned (at the bedside); 6 were discharged from the hospital and there were no cases of early sepsis, mediastinitis or thromboembolism. At follow-up, 5 patients had received transplants (50%), with 1 on LVAD support as destination therapy (10%). Survival was 60 ± 15% and 50 ± 16% at 6 and 12 months, respectively. pVPA ECMO is 100% technically feasible and is an efficient method for temporary right ventricular support after LVAD insertion with the advantage of simple bedside removal and avoidance of a PA graft remnant in the chest cavity.

Limitations of Preoperative Right Ventricular Failure Assessment in Patients Undergoing LVAD Insertion

Purpose Early right ventricular (RV) failure after LVAD is associated with increased morbidity and mortality. Several hemodynamic indices have been suggested to identify patients at risk for RV failure, however their predictive value remains unclear. Methods We retrospectively identified patients at our center who required mechanical RV support following LVAD between 2007-2018, with either surgical (Centrimag RVAD) or percutaneous (Impella RP, Protek Duo) devices. Those receiving RVAD at time of LVAD insertion were excluded. Predictors of RV failure were calculated with preoperative hemodynamics, including RA/PCWP (low risk (LR) 0.64), PAPI (LR >2, medium risk (MR) 1.5-2, HR 600 mmHg*mL/m2, MR 300-600, HR 5.5), and EUROMACS-RHF (LR 4). Results 37 patients required mechanical RV support. 18 received percutaneous RVAD and 19 surgical RVAD. Figure 1 summarizes the proportion of patients who would have been identified as low, medium, or high risk of RV failure. Mean RA/PCWP was 0.43 ± 0.19, with 13.5% of patients identified as high risk. 70.3% of patients had PAPI suggestive of low risk, with only 10.8% and 18.9% identified as medium or high risk, respectively. RVSWI identified 51.3% of patients as medium risk of RV failure and 21.6% as high risk, with mean 519 ± 316 mmHg*mL/m2. EUROMACS-RHF classified 51.3% as medium risk and 22% as high risk, while the RVFRS identified the majority of patients as low risk (83.8%). Conclusion Among patients who ultimately required mechanical support for RV failure following LVAD insertion, the majority would not have been identified as at risk using most currently available preoperative risk assessments. RVSWI and EUROMACS-RHF best predicted RV failure, identifying the majority of patients as at medium risk. In patients not identified as at risk preoperatively, easily deployed RV support may be an important means to rapidly address RV failure after LVAD insertion.

Outcomes of Minimally Invasive Temporary Right Ventricular Assist Device Support for Acute Right Ventricular Failure During Minimally Invasive Left Ventricular Assist Device Implantation.

Right ventricular failure (RVF) may still occur despite the benefits of minimally invasive left ventricular assist device (MI-LVAD) implantation. Our center strategy aims to avoid aggressive postoperative inotrope use by using mechanical support to facilitate right ventricle recovery and adaptation. We herein report first outcomes of patients with minimally invasive temporary right ventricular assist device (MI-t-RVAD) support for RVF during MI-LVAD implantation. Right ventricular failure was defined as requiring more than moderate inotopic support after weaning from cardiopulmonary bypass according to Interagency Registry for Mechanically Assisted Circulatory Support adverse event definitions. All patients requiring MI-t-RVAD support for RVF during MI-LVAD implantation between January, 2012 and April, 2016 were retrospectively reviewed. Clinical endpoints were death or unsuccessful RVAD weaning. Overall 10 patients (90% male, mean age 49.6 ± 14.8 years) underwent MI-t-RVAD implantation. Duration of MI-t-RVAD support was 16.2 ± 11.6 days. Right ventricular assist device weaning and subsequent uneventful awake device explantation was successful in all cases. The 30 day survival was 80%. Our results confirm safety and feasibility of MI-t-RVAD support for acute RVF in the setting of MI-LVAD implantation. The potential benefits of this strategy are more stable hemodynamics in the first postoperative days that usually are crucial for LVAD patients and reduced inotrope requirement.

Right ventricular assist device with membrane oxygenator support for right ventricular failure following implantable left ventricular assist device placement.

Cardiogenic shock from refractory right ventricular (RV) failure during left ventricular assist device placement is associated with high morbidity and mortality. The addition of extracorporeal membrane oxygenation to RV mechanical assistance may help RV recovery and lead to improved outcomes. We retrospectively reviewed all implanted continuous-flow left ventricular assist devices from April 2009 to June 2013. RV mechanical support was utilized for RV failure defined as haemodynamic instability despite vasopressors, pulmonary vascular dilators and inotropic therapy. RV assist devices were utilized with and without in-line membrane oxygenation. During the study period, 267 continuous-flow left ventricular assist devices were implanted. RV mechanical support was utilized in 27 (10%) patients; 12 (46%) had the addition of in-line extracorporeal membrane oxygenation. The mean age of patients with a right ventricular assist device with membrane oxygenation was lower than that in patients with a right ventricular assist device alone (45.6 ± 15.9 vs 64.6 ± 6.5, P = 0.001). Support was weaned in 66% (10 of 15) of patients with right ventricular assist device (RVAD) alone vs 83% (10 of 12) of those with RVAD with membrane oxygenation (P = 0.42). The RVAD was removed after 10.4 ± 9.4 vs 5 ± 2.99 days for patients with a RVAD with membrane oxygenation (P = 0.1). Patients with RVAD with membrane oxygenation had a 30-day mortality rate of 8 vs 47% for those with RVAD alone (P = 0.04). The survival rate after discharge was 86, 63 and 54% at 3, 6 and 12 months for both groups combined. Patients with a RVAD with membrane oxygenation support for acute RV failure after continuous-flow left ventricular assist device implantation had a lower 30-day mortality than those with a RVAD alone. Patients who survive to discharge have a reasonable 1-year survival. Combining membrane oxygenation with RVAD support appears to offer a short-term survival benefit in patients with RV failure after continuous-flow left ventricular assist device implantation.

(286) - Update on Temporary Mechanical Circulatory Support for Right Ventricular Failure

Temporary right ventricular (RV) mechanical circulatory support (MCS) is a vital adjunctive therapy for patients with RV failure (RVF). This study describes our clinical experience with temporary RV MCS in patients following post-cardiotomy cardiogenic shock (PCCS), cardiac transplant (CTx), or left ventricular assist device (LVAD) placement.

Dual Extracorporeal Membrane Oxygenation Support for Bridging Lung Transplantation in Acute Exacerbation of Idiopathic Pulmonary Fibrosis

When patients with severe respiratory failure are treated with venovenous extracorporeal membrane oxygenation (VV-ECMO), severe pulmonary hypertension due to right ventricular (RV) failure is possible. This is a serious complication that requires immediate therapeutic intervention. We report an extraordinary experience of additional venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for RV failure in a patient who was being treated with VV-ECMO as a bridge to lung transplantation. A 61-year-old man was diagnosed with acute exacerbation of idiopathic pulmonary fibrosis. While waiting for lung transplantation, he was placed on VV-ECMO and developed RV failure. After insertion of additional VA ECMO, RV dysfunction was dramatically improved. He underwent heart-lung transplantation after 23 days of dual ECMO support.

Institutional experience with extracorporeal membrane oxygenation support for right ventricular failure after left ventricular assist device implantation

Objectives: Right ventricular failure complicating left ventricular assist device implantation (LVAD) has a poor outcome. This study was designed to determine the success of extracorporeal membrane oxygenation support (ECMO) for the treatment of right ventricular failure after LVAD implantation.

Invited commentary

The article by Sadiq and colleagues [1Sadiq A. Shyamkrishnan K.G. Theodore S. Sreeram G. Tharakan J.M. Karunakaran J. Long-term functional assessment after correction of tetralogy of Fallot in adulthood.Ann Thorac Surg. 2007; 83: 1790-1796Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar] presents the topic of correction of tetralogy of Fallot in the grown-up population. The reported hospital mortality of 7%, and the causes of early death-bleeding complications in 3 patients, and multiorgan failure in 1 patient are in line with current literature. After the operation, 10 patients were reoperated on for bleeding complications, and prolonged inotropic support for right ventricular failure was necessary in 6 patients. These data affirm previous reported potential risk factors for early mortality, which are the sequelae of prolonged cyanosis, eg, myocardial fibrosis, impaired renal and hepatic function, and coagulation anomalies. Balancing the competing problems of residual right ventricular outflow tract obstruction and pulmonary insufficiency is of major concern in adults undergoing correction of tetralogy of Fallot. Although pulmonary insufficiency seems to be well tolerated in children, most authors report deleterious effects of pulmonary insufficiency during the postoperative period after correction of tetralogy of Fallot in adulthood. Sadiq and colleagues [1Sadiq A. Shyamkrishnan K.G. Theodore S. Sreeram G. Tharakan J.M. Karunakaran J. Long-term functional assessment after correction of tetralogy of Fallot in adulthood.Ann Thorac Surg. 2007; 83: 1790-1796Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar] used an intraoperative cut-point of 0.8 for the right to left ventricular pressure ratio for revising the right ventricular outflow tract. This ratio appears somewhat high, even though, it may prevent severe pulmonary insufficiency. At final follow-up, only 1 patient had severe pulmonary insufficiency, but the authors did not report the degree of pulmonary insufficiency immediately after the operation or its relationship to early mortality and morbidity. Several studies justify high operative mortality because functional status and quality of life are improved in survivors after surgical correction. However, in these studies functional status was subjectively assessed primarily according to the New York Heart Association functional class. For the first time, Sadiq and colleagues [1Sadiq A. Shyamkrishnan K.G. Theodore S. Sreeram G. Tharakan J.M. Karunakaran J. Long-term functional assessment after correction of tetralogy of Fallot in adulthood.Ann Thorac Surg. 2007; 83: 1790-1796Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar] provide objective data on exercise tolerance by performing treadmill testing in 36 patients. Accordingly, 35 patients showed good effort tolerance, and none had a positive result of exercise-induced arrhythmia, angina, or significant blood pressure changes. Nevertheless, whether or not total repair improves survival in adult patients is debatable. Because most of these patients are selected (ie, favorable morphology), the natural history of this disease can not be compared with the natural history reported for the general population of patients who have tetralogy of Fallot. Long-Term Functional Assessment After Correction of Tetralogy of Fallot in AdulthoodThe Annals of Thoracic SurgeryVol. 83Issue 5PreviewTetralogy of Fallot presenting in adulthood is a surgical challenge. We present the long-term outcomes of surgical correction in this subset of patients, including results of postoperative effort tolerance as assessed by treadmill testing. Full-Text PDF

Extracorporeal Membrane Oxygenation is Superior to Right Ventricular Assist Device for Acute Right Ventricular Failure After Heart Transplantation

Background Acute right ventricular failure after heart transplantation is a life-threatening condition, and sometimes the use of mechanical circulatory support is inevitable. The aim of this retrospective study was to investigate the effectiveness of two different mechanical circulatory support systems for this indication. Methods From 1984 to 2003, 28 heart transplant recipients exhibited right ventricular failure resistant to drug therapy. Right ventricular assist device (n = 15) or extracorporeal membrane oxygenation (n = 13) was implanted to support the failing heart. Results Overall in-hospital survival was 43%. In the right ventricular assist device group, only 2 patients (13%) could be weaned from mechanical circulatory support compared with 10 patients (77%) in the extracorporeal membrane oxygenation group ( p = 0.001). Retransplantation was necessary in 6 patients in the right ventricular assist device group and in 1 patient in the extracorporeal membrane oxygenation group ( p = 0.049). There was no difference in patient survival between groups, but graft survival was significantly better in the extracorporeal membrane oxygenation group ( p = 0.005). Conclusions In view of these results, extracorporeal membrane oxygenation seems to be the better option as mechanical circulatory support for right ventricular failure in heart transplantation.