Matteo Pozzi, Jacques Robin, Daniel Grinberg, Laurent Sebbag, Pascale Boissonnat, Élisabeth Hugon-Vallet, Claire Flamens, Sylvie Paulus, Laure Olivier-Soubirou, Jean-François Obadia
Institution : Service de chirurgie cardiaque, hôpital cardiologique Louis-Pradel, hospices civils de Lyon, université Claude-Bernard, Lyon
Objectives : Left ventricular assist devices (LVADs) display better outcome than biventricular assist devices. However right heart failure (RHF) is a common finding in end-stage heart failure as well as a life-threatening complication after LVAD implantation. The aim of this report is to describe the results of our preventive strategy of very-low threshold for indication of temporary right ventricular assist device (t-RVAD) support in LVAD recipients.
Methods : We performed a prospective observational analysis of our single-centre experience. The t-RVAD was represented by an extracorporeal membrane oxygenation (ECMO) established between the femoral vein and the pulmonary artery via a Dacron prosthesis according to an original technique.
Results : Between December 2014 and August 2016, we implanted 16 LVAD. A t-RVAD was used in 12 (75%) of them and they represented our study population (mean age 53.6 years, males 83.3%). The indication for LVAD implantation was ischemic (n=5, 41.7%) or idiopathic (n=4, 33.3%) cardiomyopathy and other (n=3, 25%). INTERMACS profile was 2 (n=2, 16.7%), 3 (n=7, 58.3%) and 4 (n=3, 25%). Device strategy was bridge-to-transplantation (n=6, 50%), bridge-to-candidacy (n=3, 25%) and destination therapy (n=3, 25%). Mean RHF risk score was 3.0 ± 1.8. Four (33.3%) patients underwent surgical re-exploration for bleeding. One (8.3%) patient experienced deep sternal wound infection requiring surgical debridement while we encountered no infections at the Dacron graft’s percutaneous exit site in the remaining 11 patients. Two (16.7%) patients died while on t-RVAD support (multiple organ failure n=1, intestinal ischemia n=1). Ten (83.3%) patients were successfully weaned off after a mean t-RVAD support of 7.0 ± 3.8 days. Weaning procedures were uneventful in awake patients on local anesthesia directly at bedside. No patient required a further mechanical circulatory support implantation for recurrent RHF. After a mean follow-up time of 6.5 ± 5.6 months, 4 (33.3%) patients died on LVAD (septic shock n=2, hemorrhagic stroke n=1, suicide n=1), 3 (25%) were alive on LVAD support and 3 (25%) were successfully bridged to heart transplantation.
Conclusion : A very-low threshold implantation of t-RVAD is a valuable strategy in LVAD recipients with a satisfactory short-term outcome in such a critically ill population.