Temporary Right Heart Support Following LVAD Implantation: A Transcutaneous Technique

Objectives: For patients with severe cardiac failure, left ventricular assist device (LVAD) implantation is a life-saving procedure. In patients with biventricular restriction, right heart failure (RHF) after LVAD implantation is a major risk factor for mortality. Occurrence of relevant RHF is difficult to predict and multiple factors contribute to this life-threatening situation. Here, we present our approach to prevent RHF following LVAD implantation using a common extracorporeal life support (ECLS) circuit and percutaneously implanted cannulas.

Methods: We analyzed the results of 10 patients (male n = 8; median age 52 year; range 18–70) undergoing LVAD implantation between November 2014 and September 2016. In case of relevant RHF, a right heart bypass (RHB) was installed. The outflow cannula was implanted via femoral vein using Seldinger technique, the place of drainage being the right atrium. The inflow cannula was inserted via the right jugular vein using a sheath through which a Swan-Ganz catheter was placed in the pulmonary artery (PA). Then, a wire was inserted and a 15French Bio-Medicus cannula was placed in the PA. Cannulas were then connected to a circuit consisting of a centrifugal pump and, if necessary, an oxygenator.

Results: Three patients required veno-arterial ECLS support before LVAD implantation, six patients required biventricular support and were placed on combined veno-arterial ECLS and left sided Impella ahead of LVAD surgery. After LVAD implantation, mean time on transcutaneous right heart bypass was 12 days (range: 3–29). In four patients, right heart function recovered and RHB was weaned. Two patients were successfully bridged to an permanent RVAD implantation, one patient was successfully bridged to heart transplantation and three patients died. All patients with successful weaning received the RHB during LVAD implantation surgery, patients with fatal outcome underwent RHB implantation with a delay of several days (range 1–38) following LVAD implantation.

Conclusion: The technique described here represents a minimally invasive method for right heart unloading with a percutaneously installed transvenous RHB for short-term support. The percutaneous approach presented here is a less invasive technique that minimizes the need for re-sternotomy and explantation is performed with local anesthesia. An early implantation of right heart support seems to provide better outcomes compared with patients with delayed implantation of RHB.