Elsevier

The Annals of Thoracic Surgery

Volume 98, Issue 6, December 2014, Pages 2122-2129
The Annals of Thoracic Surgery

Original article
Adult cardiac
Durable Ventricular Assist Device Support for Failing Systemic Morphologic Right Ventricle: Early Results

https://doi.org/10.1016/j.athoracsur.2014.06.054Get rights and content

Background

The systemic morphologic right ventricle (RV) in congenitally corrected transposition of the great arteries or after atrial switch for transposition of the great arteries is associated with late ventricular failure. Although the role of the left ventricular assist device (LVAD) in supporting the failing LV is established, the indications and outcomes of using LVAD in a systemic RV remain unclear. We assessed the role of a third-generation LVAD for systemic RV support.

Methods

Seven patients (mean age, 36 years) received the HeartWare (HeartWare International Inc, Framingham, MA) VAD for systemic RV failure (congenitally corrected transposition of the great arteries in 1 and after atrial switch in 6). Four patients (57%) had severe subpulmonic LV failure, and aggressive perioperative diuresis with or without hemofiltration was used to offload the subpulmonic LV. The indications of VAD were (1) bridge to transplant in 3 and (2) bridge to decision for a high transpulmonary gradient in 4. Transplantation outcome was compared with systemic RV failure without VAD bridge in 19 patients (years 1989 to 2013).

Results

Systemic RV support alone was achieved in all patients, with no early deaths (≤30 days). Overall, 6 (86%) returned home, 3 (44%) received a transplant, 2 (28%) died of noncardiac causes, and 2 (28%) continue on VAD support (median support, 232 days). Repeat catheterization (n = 4) showed an improved median transpulmonary gradient in 3 patients (median 18.5 mm Hg pre-VAD vs 8.0 mm Hg post-VAD). Two bridge-to-decision patients received transplants at 640 and 685 days. The stroke rate on VAD support was 43% (2 thromboembolic and 1 hemorrhagic; 3 with satisfactory recovery). De novo aortic regurgitation was 29% (n = 2; 1 valve replacement). All patients (n = 3) survived transplantation (vs 10.5% early mortality without VAD bridge; p = 1.00) and were well at follow-up (range, 53 to 700 days).

Conclusions

The third-generation VAD provides durable support for systemic RV failure as a bridge to transplant and as a strategy to reduce pulmonary vascular resistance. Although concomitant subpulmonic LV failure is common, systemic RV support alone was achieved in all patients.

Section snippets

Patients and Methods

From October 2010 to April 2014, 7 patients (6 men; mean age, 36 years [range, 26 to 41 years]; 6 post-atrial switch, 1 ccTGA; 6 redo operations) received the HeartWare HVAD (HeartWare International Inc, Framingham, MA), a third-generation LVAD, to support systemic RV failure (Table 1). Preoperative echocardiography confirmed severe systemic RV failure in all patients. Concomitant subpulmonic morphologic LV failure was also present in 6 (86%); impairment was mild to moderate in 1, moderate in

Results

Overall, 6 patients (86%) were discharged home, 3 (44%) received a transplant, and 2 (28%) died of a noncardiac cause (Fig 3). The most recent 2 patients (28%) are currently still on VAD support and are waiting for a transplant from home (median support, 232 days; range, 30 to 685 days). VAD support for the systemic ventricle alone was achieved in all patients, with no early deaths (≤30 days).

Comment

Our report shows that the third-generation continuous-flow LVAD technology can be used to provide durable support for systemic RV failure as a BTT and as a strategy to reduce PVR. The BTT patients were sicker on inotrope therapy in INTERMACS class II compared with BTD patients who were not on inotrope therapy in INTERMACS class IV. Although this is the largest series of systemic RV failure patients supported on VAD in the literature, this represents an early and evolving experience of a limited

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