Treatment Of Right Ventricular Failure Research Articles

Inhaled Pulmonary Vasodilators for the Treatment of Right Ventricular Failure in Cardio-Thoracic Surgery: Is One Better than the Others?

Right ventricular failure (RFV) is a potential complication following cardio-thoracic surgery, with an incidence ranging from 0.1% to 30%. The increase in pulmonary vascular resistance (PVR) is one of the main triggers of perioperative RVF. Inhaled pulmonary vasodilators (IPVs) can reduce PVR and improve right ventricular function with minimal systemic effects. This narrative review aims to assess the efficacy of inhaled nitric oxide and inhaled prostacyclins for the treatment of perioperative RVF. The literature, although statistically limited, supports the clinical similarity between them. However, it failed to demonstrate a clear benefit from the pre-emptive use of inhaled nitric oxide in patients undergoing left ventricular assist device implantation or early administration during heart-lung transplants. Additional concerns are related to cost safety and IPV use in pathologies associated with pulmonary venous congestion. The largest ongoing randomized controlled trial on adults (INSPIRE-FLO) is addressing whether inhaled Epoprostenol and inhaled nitric oxide are similar in preventing RVF after heart transplants and left ventricular assist device placement, and whether they are similar in preventing primary graft dysfunction after lung transplants. The preliminary analysis supports their equivalence. Several key points may be achieved by the present narrative review. When RVF occurs in the setting of elevated PVR, IPV should be the preferred initial treatment and they should be preventively used in patients at high risk of postoperative RVF. If severe refractory postoperative RVF occurs, IPVs should be combined with complementary pharmacology (inotropes and inodilators). If unsuccessful, right ventricular mechanical support should be established.

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.

PERSUADE Survey—PERioperative AnestheSia and Intensive Care Management of Left VentricUlar Assist DevicE Implantation in Europe and the United States

ObjectiveTo comprehensively assess relevant institutional variations in anesthesia and intensive care management during left ventricular assist device (LVAD) implantation. DesignProspective data analysis. SettingOnline survey. ParticipantsLVAD-centers in Europe and the United States. InterventionsAfter investigating initial interest, 91 of 202 European and 93 of 195 US centers received a link to the survey targeting institutional organization and experience, perioperative hemodynamic monitoring, medical management, and post-operative intensive care aspects. Measurements and Main ResultsThe survey was completed by 73 (36.1%) European and 60 (30.8%) US centers. Although most LVAD implantations were performed in university hospitals (>5 years’ experience), significant differences were observed in the composition of the preoperative multidisciplinary team and provision of intraoperative care. No significant differences in monitoring or induction agents were observed. Propofol was more often used for maintenance in Europe (p<0.001). Choice for inotropes changed significantly from preoperatively (more levosimendan in Europe) to intraoperatively (more use of epinephrine in both Europe and US). Use of quantitative methods for defining right ventricular function was reported more often from European compared to US centers (p<0.05). Temporary mechanical circulatory support for treatment of right ventricular failure was more often used in Europe. Nitric oxide appears to play a major role only intraoperatively. There were no significant differences in early postoperative complications reported from European vs. US centers. ConclusionsDespite the perioperative practice of care for patients undergoing LVAD implantation differs in several aspects between Europe and the US, there were no perceived differences in early postoperative complications.

Diet and Exercise Intervention in Pulmonary Hypertension

Current pharmacologic treatments for pulmonary arterial hypertension lead to vasodilation of the pulmonary arteries, increasing cardiac output and reducing pulmonary vascular resistance in patients with pulmonary arterial hypertension. Right ventricular failure is a leading cause of death in patients with pulmonary arterial hypertension, but there remain no promising leads in the treatment of right ventricular failure. Current research demonstrates that metabolic abnormalities, particularly regarding insulin resistance and glucose intolerance, may be pathologic in the development of right ventricular failure in patients with pulmonary arterial hypertension. In this review, we will address the potential role diet and exercise may play in improving right ventricular failure in patients with pulmonary arterial hypertension.

Defining early right ventricular failure during left ventricular assist device implantation: Retrospective analysis of intraoperative management

Objectives: In this study, we aimed to share the intraoperative anesthesia management of left ventricular assist device (LVAD) implantation and our approach to right ventricular failure (RVF) that developed in this process, and our results. Patients and methods: A total of 82 patients (71 males, 11 females; mean age: 49.4±9.4 years; range, 18 to 71 years) who underwent LVAD implantation between February 2013 and June 2020 were included in the retrospective study. Preoperative echocardiography, cardiac catheterization findings, and intraoperative records were reviewed. In light of the preoperative hemodynamic, echocardiographic, and preoperative echocardiographic findings of the patients, RVF levels were preoperatively determined, and a medical and mechanical support therapy algorithm for RVF was created. The postoperative outcomes were evaluated within the framework of this algorithm. Results: The mean preoperative left ventricular ejection fraction was 19.6%, and the mean right ventricular ejection fraction was 37.4%. According to our algorithm, eight (9.7%) patients developed severe, 12 (14.6%) moderate, and 48 (58.5%) mild RVF. No RVF was present in 14 (17.2%) patients. The vasoactive inotrope score was 25.7±1.3 in the advanced RVF group and compatible with the severity of RVF. Extracorporeal membrane oxygenation use was required in three (37.5%) patients who had severe RVF. Right ventricular assist device was implanted in one of the three patients with extracorporeal membrane oxygenation due to advanced RVF in the postoperative period. Mortality was observed in two (25%) patients in the advanced group, one (8.3%) in the moderate, three (6.25%) in the mild, and two (14%) in the normal RVF group. Conclusion: A standardized method for defining the RVF severity and a well-defined treatment protocol according to its degree of severity is lacking. Considering hemodynamic and echocardiographic data, grading of RVF in patients is vital for determining the treatment protocol. Treatment for RVF should be converted into standard universal algorithms.

Percutaneous Transvalvular Microaxial Flow Pump Support in Cardiology.

The Impella device (Impella, Abiomed, Danvers, MA) is a percutaneous transvalvular microaxial flow pump that is currently used for (1) cardiogenic shock, (2) left ventricular unloading (combination of venoarterial extracorporeal membrane oxygenation and Impella concept), (3) high-risk percutaneous coronary interventions, (4) ablation of ventricular tachycardia, and (5) treatment of right ventricular failure. Impella-assisted forward blood flow increased mean arterial pressure and cardiac output, peripheral tissue perfusion, and coronary blood flow in observational studies and some randomized trials. However, because of the need for large-bore femoral access (14 F for the commonly used Impella CP device) and anticoagulation, the incidences of bleeding and ischemic complications are as much as 44% and 18%, respectively. Hemolysis is reported in as many as 32% of patients and stroke in as many as 13%. Despite the rapidly growing use of the Impella device, there are still insufficient data on its effect on outcome and complications on the basis of large, adequately powered randomized controlled trials. The only 2 small and also underpowered randomized controlled trials in cardiogenic shock comparing Impella versus intra-aortic balloon pump did not show improved mortality. Several larger randomized controlled trials are currently recruiting patients or are in preparation in cardiogenic shock (DanGer Shock [Danish-German Cardiogenic Shock Trial; NCT01633502]), left ventricular unloading (DTU-STEMI [Door-To-Unload in ST-Segment-Elevation Myocardial Infarction; NCT03947619], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO], and REVERSE [A Prospective Randomised Trial of Early LV Venting Using Impella CP for Recovery in Patients With Cardiogenic Shock Managed With VA ECMO; NCT03431467]) and high-risk percutaneous coronary intervention (PROTECT IV [Impella-Supported PCI in High-Risk Patients With Complex Coronary Artery Disease and Reduced Left Ventricular Function; NCT04763200]).

Возможности коррекции легочной гипертензии у больных с тяжелым острым респираторным дистресс-синдромом, вызванным COVID-19

Актуальность. Болезнь, вызванная SARS-CoV-2, распространилась в мире с декабря 2019 года и приобрела характер пандемии. У большинства пациентов наблюдаются легкие симптомы COVID-19. Однако около 5 % больных нуждаются в лечении в отделениях интенсивной терапии из-за развития острого респираторного дистресс-синдрома (ОРДС), который может сопровождаться легочной гипертензией. Сегодня вопрос интенсивной терапии этих состояний является нерешенным и требует дальнейших исследований. Цель исследования: изучение состояния правых отделов сердца, центральной гемодинамики и влияния на них инфузии 4,2% раствора L-аргинина с 2% левокарнитином при коррекции легочной гипертензии у больных с тяжелой дыхательной недостаточностью, вызванной COVID-19. Материалы и методы. Проведено одноцентровое проспективное несравнительное исследование, в которое в течение мая — августа 2020 г. включены 39 пациентов с тяжелым течением болезни SARS-CoV-2 (COVID-19), развитием двусторонней пневмонии, ОРДС и легочной гипертензией. Проанализировано влияние инфузии 4,2% раствора L-аргинина с добавлением 2% левокарнитина на результаты интенсивной терапии. Результаты. Использование в/в инфузии 100 мл 4,2% раствора L-аргинина с 2% левокарнитином в сочетании со стандартным лечением в соответствии с приказами и протоколами МЗ Украины позволило снизить легочную гипертензию у больных с тяжелым течением COVID-19 с развитием ОРДС. Выводы. Использование раствора 4,2% L-аргинина и 2% левокарнитина у больных с тяжелым течением COVID-19 можно рассматривать как перспективный метод терапии правожелудочковой недостаточности и легочной гипертензии.

Abstract 13577: Human Induced Pluripotent Stem Cell-derived Cardiomyocyte Patches Ameliorate Right Ventricular Diastolic Dysfunction in a Rat Pressure-overloaded Right Heart Model

Introduction: Right ventricular (RV) failure following definitive repair of congenital heart diseases (CHD) have great impact on survival after surgical intervention. Recently, human induced pluripotent stem cell-derived cardiomyocyte (hiPS-CM) sheet transplantation ameliorated left ventricular dysfunction in preclinical study, associating possible efficacy in RV failure of CHD. Hypothesis: We hypothesized whether hiPS-CM patch could improve distressed RV function in rat pressure overload model. Methods: F344/NJcl- rnu/rnu rat (7-9 weeks old, male, 180-210g) underwent pulmonary artery banding (PAB) via left thoracotomy under general anesthesia. Four weeks after PAB, hiPS-CM patch transplantation to the RV was performed in the hiPS-CM patch transplantation group (n = 10), whereas a sham operation was performed in the sham group (n =10). We evaluated for cardiac catheterization (CATH) data and pathological findings 8 weeks after PAB. Results: In CATH, RV end diastolic pressure (sham; 10.0 ± 4.1 vs hiPS-CM; 5.5 ± 2.7 mmHg, P &lt; 0.01), time constant of isovolumic relaxation (sham; 24.9 ± 8.6 vs hiPS-CM; 16.5 ± 6.4 ms, P &lt; 0.01) and end-diastolic pressure volume-relation (sham; 365.6 ± 246.3 vs hiPS-CM; 214.0 ± 147.4 mmHg/mL, P &lt;0.05) were significantly ameliorated in hiPS-CM group compared with sham group. Sirius-red staining showed a significant anti-fibrotic effects in the hiPS-CM group compared with the sham group (13.4 ± 5.3 vs 20.7 ± 4.8 %, P &lt;0.05). Factor VIII stain showed that myocardial capillary vascular density in the hiPS-CM group was significantly higher than in the sham group (640 ± 131 vs 362 ± 31 units/mm 2 , P &lt;0.001). hiPS-CMs were detectable on epicardium 2 weeks after hiPS-CM patch transplantation. The expression levels of vascular endothelial growth factor and hepatocyte growth factor in the hiPS-CM group was significantly higher than in the sham group (P &lt;0.05). Conclusions: In a rat model of a pressure-overload RV, hiPS-CM patch transplantation improved the diastolic function with suppressed ventricular fibrosis and increased capillary density, suggesting a promising treatment for RV failure in CHD patients after surgical repair.

Right ventricular failure in congenital heart disease.

We aim to review select literature pertaining to congenital heart disease (CHD)-induced right ventricular (RV) function and failure. We review recent findings pertaining to children and adults with repaired tetralogy of Fallot (rTOF), systemic RV and hypoplastic left heart syndrome (HLHS). We emphasize pathophysiological mechanisms contributing to RV dysfunction in these conditions, the risk factors for adverse outcomes and the continuing challenges in treating these patients. We discuss how recent pathology findings, as well as developments in imaging and computer modeling have broadened our understanding of the pathophysiology of these conditions. We further review developments in the molecular and cellular basis of RV failure; and in particular, the RV molecular response to stress in repaired tetralogy of Fallot (rTOF). We highlight some of the genetic complexities in HLHS and how these may influence the long-term outcomes in these patients. Recent literature has led to new understandings in the pathology, pathophysiology, risk factors for adverse outcomes, molecular and genetic basis for RV dysfunction and failure in CHD. Although these findings provide new therapeutic targets, the treatment of RV failure at this time remains limited.

Oral Milrinone for the Treatment of Right Ventricular Failure in LVAD Patients

Purpose Early and late right ventricular failure (RVF) are major complications during left ventricular assist device (LVAD) support. Therapies to treat RVF are limited, leading to significant morbidity and increased mortality. Intravenous inotropes are a therapy for severe, persistent cases of RVF, but long-term use carries significant risks of infection and thrombosis associated with venous access. CRD-102 is a novel, extended-release form of oral milrinone. The aim of this study is to evaluate the safety of CRD-102 in LVAD patients with chronic RVF. Methods This is a Phase IIa, non-randomized, open-label study of CRD-102. Patients were eligible if they had a durable LVAD for more than 30 days, evidence of right ventricular dysfunction on echocardiogram, an implantable cardioverter defibrillator (ICD) and a right atrial pressure ≥ 12 mmHg. Patients with ongoing ventricular arrhythmias or uncontrolled atrial fibrillation were excluded. Hemodynamics, echocardiographic measures, ICD interrogation and biomarkers were measured before and during a 2-week period of treatment with CRD-102. Results Six patients were enrolled with mean age 64 ± 10 years, 4 male. The average duration of LVAD support was 5.0 ± 2.3 years. At baseline, mean tricuspid annular plane systolic excursion was 9.9 ± 1.3 mm, right atrial pressure was 16 ± 4 mmHg and pulmonary artery pulsatility index was 1.0 ± 0.4. Five patients completed the study and had no ventricular arrhythmias or increased incidence of atrial arrhythmias during the study period (ICD interrogation). One patient stopped study medication after an ICD shock due to ventricular fibrillation while potassium level was 2.8 mmol/L. There were no other adverse events related to therapy. During treatment, cardiac output significantly improved (5.0 ± 1.3 to 6.4 ± 1.7 L/min, p=0.008) while other hemodynamic parameters were unchanged. NT-proBNP numerically improved during the therapy, but did not reach statistical significance (1570 ± 902 to 1068 ± 390 pg/mL, p=0.3). Patient-reported quality of life improved during support. Conclusion Extended-release oral milrinone has an acceptable safety profile. Further studies are warranted to investigate the efficacy of this therapy for chronic RVF in LVAD patients.

Single Center Percutaneous Right Ventricular Assist Device Experience - 100% In-Hospital Survival Post-Left Ventricular Assist Device

Purpose Right ventricular (RV) failure is a frequent complication of left ventricular assist device (LVAD) implantation in patients with end-stage heart failure, impacting 20% of patients. Percutaneous support can be used in this scenario, however prior data supporting this approach showed survival at 30 days or hospital discharge was only 60%. Methods Retrospective review was conducted of all patients who developed severe RV failure requiring percutaneous right ventricular assist device (RVAD) following durable LVAD implant between 01/01/2017 and 07/31/2018. Patient demographics were reviewed in addition to key hemodynamic and laboratory values were collected pre-RVAD implantation and at the time of explant (post-RVAD). Pre-RVAD and post-RVAD data was compared using paired T tests. Survival at 30 days or at date of hospital discharge (whichever was longer) was considered as the primary outcome. Patient hemodynamic measures were evaluated as secondary outcomes. Results Of 41 patients who received LVAD, 10 (24%) developed severe RV failure postoperatively. Baseline characteristics include age 51±14.5 years, with 30% females. Incidence of ischemic cardiomyopathy was 20%. Most patients received LVAD as destination therapy (80%). RVAD support via percutaneous cannulation was maintained for a median duration of 15.5 days (Range - 7 to 23 days). Survival at 30 days or to hospital discharge was 100%. We observed a reduction in central venous pressure from 17.2±4.5 mm(Hg) to 11±3.1 mm(Hg), p=0.004 and an increase in LVAD flow from 4.5±0.8 l/min to 5.1±0.4 l/min, p=0.018. There was a trend towards increase in mixed venous oxygen saturation from 61.5±11.1% to 67.0±7.0%, p=0.224. Conclusion Percutaneous RVAD cannulation for treatment of RV failure after LVAD implantation provides superior early postoperative survival than traditional management techniques. These findings support broader implementation of this technique to further characterize its benefit.

Лечение правожелудочковой недостаточности в ближайшем послеоперационном периоде у детей старшего возраста с врожденными пороками сердца, перенесших вмешательство на открытом сердце

&lt;p&gt; &lt;b&gt;Цель исследования&lt;/b&gt; – разработка концепции (стратегии) лечения правожелудочковой недостаточности в ближайшем послеоперационном периоде у детей старшего возраста с врожденными пороками сердца, перенесших вмешательство на открытом сердце. &lt;p&gt; &lt;b&gt;Материал и методы.&lt;/b&gt; Основу данного исследования составили материалы клинических наблюдений 65 пациентов, проведенных в ближайшем послеоперационном периоде у больных, перенесших хирургическое вмешательство на открытом сердце за период с 2014 по 2018 г. У всех 65 пациентов в ближайшем послеоперационном периоде развилась правожелудочковая недостаточность. Возраст больных составил в среднем 3,0±0,36 года, рост 90,1±2,8 см, вес 13,9±1,3 кг. Пациентов женского пола было 32, мужского – 33. Основная нозологическая характеристика пациентов включала несколько различных диагнозов: тетрада Фалло (21 пациент), двойное отхождение сосудов от ПЖ (17 пациентов), атрезия легочной артерии (10 больных), дефект межжелудочковой перегородки (МЖП) (10 пациентов), аномалия Эбштейна и гипертрофическая кардиомиопатия (по 2 больных), транспозиция магистральных артерий (3 пациента). По данным УЗИ определяли нарушение движения МЖП, конечный диастолический и систолический объем ЛЖ, фракцию выброса (ФВ) ЛЖ, ударный объем (УО). Для определения параметров центральной гемодинамики пользовались общепринятыми формулами. Для компенсации правожелудочковой недостаточности была налажена внутривенная инфузия норадреналина. Во время проводимого исследования выполнялось 5 измерений, отражающих параметры центральной гемодинамики и изменения в движении МЖП. &lt;p&gt; &lt;b&gt;Результаты.&lt;/b&gt; После того как была налажена внутривенная инфузия норадреналина, артериальное давление поднялось, частота сердечных сокращений и центральное венозное давление (ЦВД) снизились. УО и сердечный индекс возросли, КДО ЛЖ увеличился до исходных значений. Потребление тканями кислорода и доставка кислорода увеличились. При этом общее периферическое сопротивление (ОПС) увеличилось до нормальных показателей. Доза адреналина была снижена и доведена до терапевтической. Когда контрактильная способность правого желудочка восстановилась, дозу норадреналина плавно снижали. &lt;p&gt; &lt;b&gt;Заключение.&lt;/b&gt; Использование норадреналина при правожелудочковой недостаточности позволяет наладить перфузию ПЖ, как в систолу, так и в диастолу, за счет роста давления в аорте и снижения уровня ЦВД. Инфузия норадреналина приводит к снижению давления в ПЖ и правом предсердии, что способствует хорошему оттоку по венозной системе ПЖ. Все это в конечном счете и приводит к росту контрактильности ПЖ, восстановлению движения МЖП. Компенсацию (разрешение) правожелудочковой недостаточности следует определять по увеличению КДО ЛЖ до должного (исходного) значения (при сохраненной его ФВ), увеличивающемуся при этом УО и снижению ЦВД, опираясь при этом на значения ОПС. HTML

Levosimendan in pulmonary hypertension and right heart failure.

Pulmonary hypertension is a multifactorial disease with a high morbidity and mortality. Right ventricular function is the most important predictor of morbidity and mortality in patients suffering from pulmonary hypertension, but currently there are no approved treatments directly supporting the failing right ventricle. Levosimendan is a calcium sensitizing agent with inotropic, pulmonary vasodilatory, and cardioprotective properties. Given its pharmacodynamic profile, levosimendan could be a potential novel agent for the treatment of right ventricular failure caused by pulmonary hypertension. The aim of this review is to provide an overview of the current knowledge on the effects of levosimendan in pulmonary hypertension and right heart failure.

Reversal of right ventricular remodeling by dichloroacetate is related to inhibition of mitochondria-dependent apoptosis.

Most patients with pulmonary arterial hypertension die from right ventricular failure (RVF). Right ventricular (RV) myocardial apoptosis has an important role in RVF and is regulated by the mitochondria. Dichloroacetate (DCA) can improve cardiac function in RVF, but whether it can regulate myocardial apoptosis via mitochondria is still unknown. In this study, we investigated the effects of DCA on myocardial mitochondria, the mitochondrial apoptosis and other aspects of RV remodeling, including fibrosis and capillary rarefaction. RVF was induced in rats by a single s.c. injection of monocrotaline. After 4 weeks, DCA treatment was started with i.p. injection of 50, 150 or 2007 mg kg(-1) per day during 14 days. Compared with saline-treated RVF animals, treatment with DCA resulted in decreased mean pulmonary arterial pressure and total pulmonary resistance (TPR), and increased cardiac output. The expression of pyruvate dehydrogenase kinase was suppressed, while pyruvate dehydrogenase expression was upregulated with DCA application. DCA treatment was also associated with restored RV mitochondrial function and a reduction in RV hypertrophy, fibrosis, capillary rarefaction and apoptosis. Mitochondria-dependent apoptosis was involved in DCA regulation of RV. The absent correlation between TPR and main parameters in RV suggests that the effects of DCA in the two organ systems are independent. We conclude that DCA improves cardiac function in experimental RVF partly by reversing RV remodeling, restoring mitochondrial function and regulating mitochondria-dependent apoptosis. The study shows that a fear for increased RV apoptosis with DCA treatment is unnecessary and suggests a potential role of DCA in the treatment of RVF.

Right Ventricular Recovery Induced by Temporary Right Ventricular Assist Device Support

Background: Right ventricular failure is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. The potential for right ventricular recovery induced by mechanical assistance and exact guidelines for right ventricular assist device (RVAD) weaning still need to be defined. Methods: Between January 2008 and October 2013 a total of 584 adults preselected by echocardiography underwent long-term rotary blood pump implantation at our center. Sixty-nine patients required temporary RVAD insertion for treatment of right ventricular failure after the initiation of LVAD support. Results: Thirty-three patients on RVAD reached candidacy for weaning after a median of 6 (range 1–36) days of full RVAD support. Four of them were non-weanable: one received heart transplantation after 24 days, 3 patients were successfully bridged to long-term implantable RVADs after 15, 50 and 154 days on temporary support, respectively. In 2 patients weaning was interrupted due to onset of sepsis and late tamponade (both died on RVAD after 25 and 39 days). Weaning patients (n = 27) required a median support duration of 20 (range 3–65) days. At last follow-up LVAD outpatients (n = 19, 13.2 ± 5.3 months, cumulative support 25 patient/years) showed stable right ventricular function after previous weaning from temporary RVAD. Conclusion: In general, the outcomes of patients who require unplanned implantation of a temporary RVAD after LVAD insertion are still unsatisfactory. However, once patients in our study had reached weaning candidacy, the procedural success rate rose to 90% with right ventricular myocardial recovery allowing weaning of over 80%. Weaned patients achieve acceptable functional status, right ventricular function and LVAD flow in outpatient studies.

Selective reduction of afterload in right heart assist therapy: a mock loop study

The treatment of right ventricular failure is closely linked to effects on pulmonary vascular resistance and thus the right ventricular (RV) afterload. Medical therapy includes afterload-decreasing drugs such as nitric oxide and prostacycline. However, current devices for mechanical unloading of the right ventricle aim at a decrease in preload increasing the pulmonary volume loading. In our concept study, we tested a minimally invasive right ventricular assist device (MIRVAD) that specifically reduces the afterload. The MIRVAD is supposed to be a foldable device for temporary transvascular placement in the pulmonary artery. We incorporated a MIRVAD prototype into a mock circulatory loop that can reproduce haemodynamic interaction between the pump and the physiological system. Pulmonary hypertension (PH), right heart failure (RHF) and MIRVAD-assisted cases were simulated. The key haemodynamic parameters for RV unloading were recorded. Mock loop simulation attested to a sufficient right ventricular unloading by serial application of a miniaturized impeller pump in the pulmonary artery. The afterload, represented by the pulmonary arterial root pressure, was recovered to the healthy range (32.62-10.93 mmHg) for the simulated PH case. In the simulated RHF case, the impaired pulmonary perfusion increased from 43.4 to 88.8% of the healthy level and the total ventricular work reduced from 0.381 to 0.197 J at a pump speed of 3500 rpm. At pump speeds higher than 3500 rpm, the pulmonary valve remains constantly open and the right ventricular configuration changes into a simple perfused hollow body. The feasibility of RV unloading by a selective decrease in RV afterload was proved in principle. By alternation of the pump speed, gradual reloading in sense of a myocardial training may be achieved. The results will be validated by future animal trials where the relationship between the level of support and pulmonary vascular pressure can be investigated in vivo. Further device design concerning foldable impeller leaflets will be carried out. At a final stage, the crimped version is supposed to reach a size below 1 cm to facilitate minimally invasive insertion.

Assessment and treatment of right ventricular failure

Right ventricular (RV) failure is a complex problem with poor outcomes. Diagnosis requires a high degree of clinical suspicion, because many of the signs and symptoms of this condition are nonspecific and can be acute or chronic. Identification of the underlying aetiology, which can include pulmonary hypertension, cardiomyopathy, myocardial infarction, congenital or valvular heart disease, and sepsis, is essential. Echocardiography is the technique of choice for first-line assessment, but cardiac MRI is the current gold standard for anatomical and functional assessment of the right ventricle. Therapy for RV failure should be directed at the underlying cause, although management of symptoms is also important. Therapeutic options range from pharmacological treatment to mechanical RV support and heart transplantation. The complex 3D geometry of the right ventricle and its intricate interactions with the left ventricle have left many questions about RV failure unanswered. However, promising new targeted therapies are under development and mechanical support is becoming increasingly feasible. The next decade will be an exciting time for advances in our understanding and management of RV failure.

Remove the afterload – a new position in the treatment of right ventricular failure

Remove the afterload – a new position in the treatment of right ventricular failure

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.

Effect of Nesiritide in Isolated Right Ventricular Failure Secondary to Pulmonary Hypertension

Treatment of right ventricular failure (RVF) can be challenging due to the correlation between RVF and worsening renal function with diuretic therapy. Nesiritide has been studied in patients with left ventricular failure but has not been evaluated in isolated RVF. The authors retrospectively analyzed 140 patients admitted with RVF, pulmonary hypertension (PH), and preserved left ventricular systolic function. Seventy patients were treated with nesiritide while the remaining patients received only furosemide (no nesiritide group). Serum creatinine and GFR at baseline, 72 hours, discharge, and 1 month post-treatment, as well as hemodynamic data were compared between the groups. In the nesiritide group, there was a significant decrease in mean GFR (42.77±25.33, P<.001) at day of discharge and 1 month post-nesiritide infusion (41.17±24.94, P<.001) but not in the no nesiritide group. There was a significant difference in >25% decrease in GFR anytime through day 30 (47.14% vs. 25.71%, P=.036) between the two groups. On multivariate analysis, nesiritide remained an important predictor of renal function at discharge and at 1 month (P<.01) as well as a predictor of >25% decrease in GFR anytime through day 30 (P=.007). Thus, nesiritide is associated with worsening kidney function in patients with RVF in the setting of PH.