Can perioperative right ventricular support avoid postoperative right heart failure in patients with biventricular failure undergoing left ventricular assist device implantation?

Objective: Depending on the pre-existing condition of the right ventricle (RV), the left ventricular assist device (LVAD) may have a detrimental effect by increasing preload to an already compromised RV with subsequently right heart failure (RHF). This study details one centre's experience with perioperative right ventricular support in patients with preoperative RV dysfunction undergoing LVAD implantation.

Methods: Fourteen patients who underwent LVAD implantation between February 2011 and February 2012 were retrospectively analysed. In all patients the RV support was implanted before weaning from cardiopulmonary bypass. Preoperative RV function was assessed by echocardiography and right heart catheter.

Results: All patients showed reduced right ventricular function with elevated right ventricular systolic pressure 56.7 ± 16.9 mmHg and reduced TAPSE of 16 ± 5 mm. The mean CVP was 17.5 ± 9 mmHg. A dilatation of the tricuspid annulus (> 35 mm) with moderate to severe tricuspid valve insufficiency was found in all patients and was repaired by tricuspid valve annuloplasty. After removal of the RV support none of the patients developed RHF, the mean inotropic support 24 hours thereafter was 0.016 ± 0.03 µg/kg/min epinephrine. RV support was removed 7 ± 4 days after LVAD implantation. Three patients died due to pneumonia with consecutive sepsis in the follow-up. Overall survival was 78.57%.

Conclusion: The use of perioperative RV support during LVAD surgery can avoid postoperative RV failure in patients with preoperative biventricular failure undergoing LVAD implantations, who otherwise were candidates for biventricular assist device. RV support allowed time for the already compromised right ventricle to get attuned to the increasing preload, avoids distension and RV failure.