Abstract
Management of RV failure at the time of LVAD implantation is often difficult, and institution of emergency RVAD support leads to poor outcomes in these patients. We want to share our experience of a simplified, less traumatic temporary surgical RVAD support during LVAD implant, which allows safe post-operative care and rehabilitation, as well as allow an easy removal under local anaesthetic (LA).
Between 2012-2020, we identified 178 patients undergoing LVAD implantation in our unit. In 41 patients (23%), temporary RVAD support was needed due to failure to wean from CPB. Patients who required delayed RVAD support were excluded (n=12). The RVAD implant consisted of a 8 mm outflow graft onto the main pulmonary artery, and tunnelled via the left chest. The venous inflow via the sapheno-femoral junction. This technique allowed safe mobilization of the patient during their post-operative rehabilitation. The decannulation is performed under LA without resternotomy.
A total of 29 patients were included in this study. There were 23 males and 6 females with a mean age of 51.1 years (range 12-68). Pre-operative diagnosis was DCM in 17 (58.6%), ICM in 8 (27.6%), giant cell myocarditis in 2 (6.9%) and others in 4 (13.7%). The median INTERMACS class was 2. 22/29 patients (75.8%) were successfully weaned from RVAD support. In those that failed to wean, five (17.2%) were transplanted super-urgently while another two patients (6.9%) died of multi-organ failure. Median RVAD support was 7 days (range 3-28). Post-operative complications occurred in 20/29 patients (68.9%). Bleeding/tamponade occured in 11/29 (37.9%) - six patients required re-exploration. One patient (3.4%) had bleeding from the PA graft - he was reopened after his RVAD was weaned off. RVAD support was reinstituted for a further 13 days. Median ICU LOS was 12 days (range 5-33) and median hospital LOS was 40 days (range 5-149). 25/29 patients (86.2%) were discharged home and the 30-day survival was 89.6%.
Our simplified temporary RVAD technique is a safe and less invasive surgical approach to allow for successful LVAD implant in patients with severe RV failure. This allows significant improvement in perioperative management including rehabilitation on ICU. The rate of complications is low and the explant procedure easy with minimal trauma.