Perioperative Use of TandemHeart Percutaneous Ventricular Assist Device in Surgical Repair of Postinfarction Ventricular Septal Defect

Abstract

Mortality for patients presenting with acute myocardial infarction (AMI) complicated by ventricular septal defect (VSD) and cardiogenic shock is very high even with surgical repair. We report our experience regarding utilization of TandemHeart, a percutaneous ventricular assist device (pVAD) as an adjunct to the treatment of these patients. Retrospective case series study design included a total of 11 patients with post-AMI VSD and severe refractory cardiogenic shock who received pVAD support at our institution. Three patients underwent immediate surgical repair and received pVAD support for postcardiotomy cardiogenic shock for 2, 4, and 7 days, respectively. However, all three died. The other eight patients had pVAD implanted prior to surgical repair in order to rest the myocardium before operation. Hemodynamics improved immediately after pVAD placement, and after receiving pVAD support for 7 ± 3 days, they underwent surgical VSD repair. Their total pre- and post-surgical pVAD support was 14 ± 4 days. All eight survived 30 days postoperatively. At 6 months postsurgery overall survival rate was 75%. Our small series of these critically ill patients shows a trend toward better survival after immediate pVAD placement to stabilize the patient and allow for myocardial maturation before surgical VSD repair.

Transcatheter treatment of postinfarct ventricular septal defects

“…Alternative mechanical circulatory support (MCS) devices have been used in small series for postinfarct VSD. These include Impella,27–29 TandemHeart30 and veno-arterial extra corporeal membrane oxygenation (VA-ECMO) 31 32. A computer simulation model to evaluate the effectiveness of different MCS devices for postinfarct VSD33 found that no device normalised haemodynamics, and the ratio of pulmonary to systemic flow (Qp:Qs ratio) could not be reduced below 2.0.…”

Preoperative Venoarterial Extracorporeal Membrane Oxygenation Slashes Risk Score in Advanced Structural Heart Disease

“…Current guidelines for cardiac surgery in heart failure patients recommend preparation for MCS as salvage therapy, with no data to recommend preoperative use [1,2]. Preoperative ECMO before repair of structural heart disease has been described in isolated reports [21][22][23][24][25]. Few of the existing reports present ECMO as a means to improve postoperative outcome, none taking full advantage of organ recovery, diuresis, nutrition, or patient mobilization.…”

“…Few of the existing reports present ECMO as a means to improve postoperative outcome, none taking full advantage of organ recovery, diuresis, nutrition, or patient mobilization. One series from Gregoric and colleagues [25] compared 8 patients that received a percutaneous assist device (TandemHeart, LivaNova, Houston, TX) before repair of ischemic VSD with 3 patients that required the device postoperatively. They demonstrated markedly improved survival as well as physiologic improvement with preoperative MCS support.…”

Total artificial heart in patients with post-infarction ventricular septal defect

“…In the overall population undergoing surgical VSD repair, there is a significant survival advantage in delaying surgery for at least seven days (1). However, during the waiting period, the risk is high for developing cardiogenic shock or expansion of the VSD to the point of being inoperable (5).…”