Comparison of Biventricular and Left Ventricular Assist Devices for the Management of Severe Right Ventricular Dysfunction in Patients with End-Stage Heart Failure

Abstract

Right ventricular failure (RVF) exposes ventricular assist device (VAD) recipients to a high risk of death, but its management has not yet been standardized. We report three separate management strategies used for VAD recipients that present with RVF at a single center: 1) Thoratec paracorporeal biventricular VAD implantation, 2) left ventricular assist device (LVAD) implantation with temporary CentriMag right ventricular assist device (RVAD), and 3) LVAD combined with inotropic therapy. We retrospectively compared the preoperative data, the clinical outcomes, and the rates of adverse events in 84 biventricular assist device (BiVAD) recipients and 89 LVAD recipients presenting with postoperative RVF (57 were treated with a temporary RVAD and 32 were managed medically). Risk factors for death were analyzed. The BiVAD recipients were significantly younger, more critically ill at the time of device implantation, and required extracorporeal membrane oxygenation, an intraaortic balloon pump, mechanical ventilation, inotropes, or cardiopulmonary resuscitation significantly more often (at the time of device implant) than the LVAD recipients with RVF. The 6 month mortality was comparable in the two groups: 44 BiVAD patients (52%) and 38 LVAD patients (43%). Age, previous cardiac surgery, low platelet count, increased creatinine levels, the use of preoperative mechanical ventilation, and the need for a temporary RVAD were associated with 6 month mortality. The occurrence of RVF at the time of device implantation is a severe situation; it is associated with excess mortality, even if it is managed using a BiVAD or a LVAD with a temporary RVAD, probably because of the high preoperative risk profiles of the patients. In all cases, RVF must be managed quickly.

Are biventricular assist devices underused as a bridge to heart transplantation in patients with a high risk of postimplant right ventricular failure?

“…1 RV failure occurs in up to 50% of patients after left ventricular assist device (LVAD) implantation and is strongly associated with increased mortality and morbidity. 1,2 Despite later conversion to biventricular assist device (BiVAD) support, such patients have a worse outcome compared with those managed with LVAD alone. 3 Poor survival among those with BiVAD support is not entirely unexpected because this therapy may arise from a subsequent conversion from LVAD, at a time when multiple organ failure developed.…”

Short-term mechanical circulatory support as bridge to heart transplantation: paracorporeal ventricular assist device as alternative to extracorporeal life support

“…During the last decade, intracorporal implantable LVADs have been widely adopted as a bridge to HTx. Unfortunately, these devices are not the best therapeutic option when the patient is in cardiogenic shock showing biventricular involvement and initial multiorgan dysfunction (24)(25)(26).…”

“…The absence of the oxygenator can potentially lower the impact of inflammation and coagulation imbalance and offer a more physiologic blood flow both in uni-or biventricular configurations. Despite a more demanding surgical approach, pneumatic paracorporeal devices may represent an appealing alternative to ECLS, not only by reducing the oxygenator-related complications, but also by Liver dysfunction 8 [24] Peripheral vascular disease 2 [6] Atrial fibrillation 8 [24] BMI, body mass index; BSA, body surface area; COPD, chronic obstructive pulmonary disease. offering a longer circulatory support compared to ECLS and centrifugal pumps, allowing thereby a safer organ donor allocation and a better multiorgan recovery and preservation: indeed, long-term circulatory support can improve end-organ function, even to complete recovery and permit the optimization of a patient's fitness and nutritional status before HTx.…”

Understanding Left Ventricular Assist Devices

“…The therapies aim to maintain RV function and reduce preload and afterload. Temporary MCS may be useful [22,23].…”