Abstract
Severe RV failure following LVAD implantation leads to significantly worse outcomes. Currently, there is a paucity of evidence in the literature, and they are limited to observational studies in single centres. We present our single centre experience of performing planned RVAD support for severe RV failure at the time of LVAD implantation, after an initial attempt to wean off CPB. The outflow cannula is via an 8mm graft onto the PA and tunnelled through the chest, and the inflow is via the sapheno-femoral junction.
Between 2012 and 2020, we identified 178 patients undergoing LVAD implantation in our unit. In 41 patients (23%), temporary RVAD support was necessary due to failure to wean from CPB. Patients who required RVAD support post-operatively were excluded (n=12).
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%). Three patients (10.3%) had prior sternotomy. The median INTERMACS class was 2. 22/29 patients (75.8%) were successfully weaned from RVAD support. Seven patients (24.1%) were unable to be weaned. Five (17.2%) were transplanted super-urgently while 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 was the most common complication 37.9% - six patients required re-exploration and five patients had GI bleeding. Renal failure occurred in 20.7%, arrhythmias in 17.2% and pulmonary complications occurred in 10.3%. Median ICU and hospital LOS were 12 days (range 5-33) and 40 days (range 5-149) respectively. 25/29 patients (86.2%) were discharged home (3 were transplanted from BIVAD). A total of 13 patients (44.8%) were transplanted. 30-day survival was 89.6%. One-, and Two-year survival was 62.0% and 44.5% respectively. Mean survival was 24.5 months.
Planned RVAD support at the time of LVAD implantation can be done in a safe, less invasive and simple fashion as our experience has shown. This allows us to navigate the difficulties in management of RV failure with short duration of support, simple explant, easier rehabilitation of patients on ICU and allows for a timely discharge for the patients.