European Journal of Cardio-Thoracic Surgery Advance Access published April 15, 2015
ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery (2015) 1–5 doi:10.1093/ejcts/ezv116
Right ventricular assist device with membrane oxygenator support for right ventricular failure following implantable left ventricular assist device placement Jeremy Leidenfrost, Sunil Prasad, Akinobu Itoh*, Christopher Lawrance, Jennifer M. Bell and Scott C. Silvestry Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA * Corresponding author. Department of Surgery, Division of Cardiothoracic Surgery, Campus Box 8234, 660 S. Euclid Avenue, St. Louis, MO 63110, USA. Tel: +1-314-3628837; fax: +1-314-7474216; e-mail: [email protected]; [email protected] (A. Itoh). Received 24 October 2014; received in revised form 5 February 2015; accepted 17 February 2015
Abstract OBJECTIVES: Cardiogenic shock from refractory right ventricular (RV) failure during left ventricular assist device placement is associated with high morbidity and mortality. The addition of extracorporeal membrane oxygenation to RV mechanical assistance may help RV recovery and lead to improved outcomes. METHODS: We retrospectively reviewed all implanted continuous-flow left ventricular assist devices from April 2009 to June 2013. RV mechanical support was utilized for RV failure defined as haemodynamic instability despite vasopressors, pulmonary vascular dilators and inotropic therapy. RV assist devices were utilized with and without in-line membrane oxygenation. RESULTS: During the study period, 267 continuous-flow left ventricular assist devices were implanted. RV mechanical support was utilized in 27 (10%) patients; 12 (46%) had the addition of in-line extracorporeal membrane oxygenation. The mean age of patients with a right ventricular assist device with membrane oxygenation was lower than that in patients with a right ventricular assist device alone (45.6 ± 15.9 vs 64.6 ± 6.5, P = 0.001). Support was weaned in 66% (10 of 15) of patients with right ventricular assist device (RVAD) alone vs 83% (10 of 12) of those with RVAD with membrane oxygenation (P = 0.42). The RVAD was removed after 10.4 ± 9.4 vs 5 ± 2.99 days for patients with a RVAD with membrane oxygenation (P = 0.1). Patients with RVAD with membrane oxygenation had a 30-day mortality rate of 8 vs 47% for those with RVAD alone (P = 0.04). The survival rate after discharge was 86, 63 and 54% at 3, 6 and 12 months for both groups combined. CONCLUSIONS: Patients with a RVAD with membrane oxygenation support for acute RV failure after continuous-flow left ventricular assist device implantation had a lower 30-day mortality than those with a RVAD alone. Patients who survive to discharge have a reasonable 1-year survival. Combining membrane oxygenation with RVAD support appears to offer a short-term survival benefit in patients with RV failure after continuous-flow left ventricular assist device implantation. Keywords: Ventricular assist device • Membrane oxygenation • Right ventricular failure
INTRODUCTION With the increasing incidence of end-stage heart failure and stable donor availability, there is an increasing demand for both bridging and destination left ventricular assist devices (LVADs). With increasing LVAD use, the expertise of multidisciplinary teams in caring for patients in end-stage heart failure has improved, as has survival for this patient population. Poor right ventricular (RV) performance is a major limitation to patient selection for LVAD implantation. Patients who develop cardiogenic shock from acute RV failure during continuous-flow left ventricular assist device (cfLVAD) placement have extremely high morbidity and mortality. In this setting, external continuous-flow devices are frequently employed for temporary RV mechanical support [1]. Alternatively, veno-arterial extracorporeal membrane oxygenation (ECMO) has been reported for circulatory support for RV failure after LVAD
implantation with increasing frequency [2]. The addition of an oxygenator to a right ventricular assist device (RVAD) circuit (RVAD-MO) has been reported in paediatric cardiac transplant for acute RV failure [3, 4]. We have increasingly utilized RVAD plus membrane oxygenation for acute RV failure causing cardiogenic shock following LVAD implantation. We report our series of 267 continuous-flow LVADs of which 27 patients underwent temporary RVAD implantation at the time of LVAD implantation. Of those who had mechanical RV support, 12 patients had a membrane oxygenator placed in line at the time of RVAD placement.
MATERIALS AND METHODS We conducted a single-centre retrospective review of our clinical quality assurance database for all patients undergoing implantable
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
TX & MCS
Cite this article as: Leidenfrost J, Prasad S, Itoh A, Lawrance C, Bell JM, Silvestry SC. Right ventricular assist device with membrane oxygenator support for right ventricular failure following implantable left ventricular assist device placement. Eur J Cardiothorac Surg 2015; doi:10.1093/ejcts/ezv116.
2
J. Leidenfrost et al. / European Journal of Cardio-Thoracic Surgery
cfLVAD from March 2009 to June 2013. The study protocol was approved by the Washington University Human Research Protection Office with a waiver for patient consent. RV failure requiring RVAD support was defined as patients who had inadequate cardiac output, elevated central venous pressure and poor LVAD filling despite maximal vasopressor, pulmonary vascular dilatation and inotropic therapy. The decision to implant is a multidisciplinary decision made by both the surgical and anaesthesia critical care teams (Fig. 1). During this time period, 267 cfLVADs were implanted, with 27 patients treated for perioperative RV failure by RVAD placement. RVADs were weaned per our protocol. We analysed survival at discharge, 3 months, 6 months and 1 year. RVADs utilized were 25 Centrimag (Thoratec, Pleasanton, CA, USA), 1 Impella LD (Abiomed, Inc., Danvers, MA, USA) (implanted retrograde through the pulmonary artery into the right ventricle) and 1 Abiomed 5000 (Abiomed, Inc., Danvers, MA, USA).
Right ventricular assist device implantation All devices are implanted through a median sternotomy incision. cfLVAD implantation is performed on cardiopulmonary bypass. The patient is then weaned from cardiopulmonary bypass with inotropes. In patients with poor RV function preoperatively or post-pump RV dysfunction, inhaled pulmonary vasodilators (epoprostenol and nitric oxide) are added and titrated for maximal effect. The cfLVAD revolutions per minute is increased under transoesophageal echocardiographic (TOE) guidance. In cases where cfLVAD flow continues to be low due to complete collapse of the LV chamber despite maximal inotropic and pulmonary
vasodilator support, RV mechanical support is added. Cannula selection varies with implanting surgeon variations in anatomy expected, and duration of device therapy. Venous cannulation is undertaken using a malleable 36-French venous cannula through the right atrial appendage, and typically arterial cannulation is performed using a 10-mm graft anastomosed to the main pulmonary artery. Patients are assessed for oxygenator placement in the RVAD circuit. Patients who receive RVAD-MO after cfLVAD receive an in-line Quadrox Oxygenator (Maquet, Rastatt, Germany) in the RVAD circuit. Cannulas are brought out subxiphoid and connected to the circuit. Patients are packed and the chest left open for refractory bleeding. Postoperatively, the activated clotting time (ACT) is allowed to normalize, platelet count is maintained at >150 000, and fibrinogen is kept at >200 mg/l and INR at
ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery (2015) 1–5 doi:10.1093/ejcts/ezv116
Right ventricular assist device with membrane oxygenator support for right ventricular failure following implantable left ventricular assist device placement Jeremy Leidenfrost, Sunil Prasad, Akinobu Itoh*, Christopher Lawrance, Jennifer M. Bell and Scott C. Silvestry Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA * Corresponding author. Department of Surgery, Division of Cardiothoracic Surgery, Campus Box 8234, 660 S. Euclid Avenue, St. Louis, MO 63110, USA. Tel: +1-314-3628837; fax: +1-314-7474216; e-mail: [email protected]; [email protected] (A. Itoh). Received 24 October 2014; received in revised form 5 February 2015; accepted 17 February 2015
Abstract OBJECTIVES: Cardiogenic shock from refractory right ventricular (RV) failure during left ventricular assist device placement is associated with high morbidity and mortality. The addition of extracorporeal membrane oxygenation to RV mechanical assistance may help RV recovery and lead to improved outcomes. METHODS: We retrospectively reviewed all implanted continuous-flow left ventricular assist devices from April 2009 to June 2013. RV mechanical support was utilized for RV failure defined as haemodynamic instability despite vasopressors, pulmonary vascular dilators and inotropic therapy. RV assist devices were utilized with and without in-line membrane oxygenation. RESULTS: During the study period, 267 continuous-flow left ventricular assist devices were implanted. RV mechanical support was utilized in 27 (10%) patients; 12 (46%) had the addition of in-line extracorporeal membrane oxygenation. The mean age of patients with a right ventricular assist device with membrane oxygenation was lower than that in patients with a right ventricular assist device alone (45.6 ± 15.9 vs 64.6 ± 6.5, P = 0.001). Support was weaned in 66% (10 of 15) of patients with right ventricular assist device (RVAD) alone vs 83% (10 of 12) of those with RVAD with membrane oxygenation (P = 0.42). The RVAD was removed after 10.4 ± 9.4 vs 5 ± 2.99 days for patients with a RVAD with membrane oxygenation (P = 0.1). Patients with RVAD with membrane oxygenation had a 30-day mortality rate of 8 vs 47% for those with RVAD alone (P = 0.04). The survival rate after discharge was 86, 63 and 54% at 3, 6 and 12 months for both groups combined. CONCLUSIONS: Patients with a RVAD with membrane oxygenation support for acute RV failure after continuous-flow left ventricular assist device implantation had a lower 30-day mortality than those with a RVAD alone. Patients who survive to discharge have a reasonable 1-year survival. Combining membrane oxygenation with RVAD support appears to offer a short-term survival benefit in patients with RV failure after continuous-flow left ventricular assist device implantation. Keywords: Ventricular assist device • Membrane oxygenation • Right ventricular failure
INTRODUCTION With the increasing incidence of end-stage heart failure and stable donor availability, there is an increasing demand for both bridging and destination left ventricular assist devices (LVADs). With increasing LVAD use, the expertise of multidisciplinary teams in caring for patients in end-stage heart failure has improved, as has survival for this patient population. Poor right ventricular (RV) performance is a major limitation to patient selection for LVAD implantation. Patients who develop cardiogenic shock from acute RV failure during continuous-flow left ventricular assist device (cfLVAD) placement have extremely high morbidity and mortality. In this setting, external continuous-flow devices are frequently employed for temporary RV mechanical support [1]. Alternatively, veno-arterial extracorporeal membrane oxygenation (ECMO) has been reported for circulatory support for RV failure after LVAD
implantation with increasing frequency [2]. The addition of an oxygenator to a right ventricular assist device (RVAD) circuit (RVAD-MO) has been reported in paediatric cardiac transplant for acute RV failure [3, 4]. We have increasingly utilized RVAD plus membrane oxygenation for acute RV failure causing cardiogenic shock following LVAD implantation. We report our series of 267 continuous-flow LVADs of which 27 patients underwent temporary RVAD implantation at the time of LVAD implantation. Of those who had mechanical RV support, 12 patients had a membrane oxygenator placed in line at the time of RVAD placement.
MATERIALS AND METHODS We conducted a single-centre retrospective review of our clinical quality assurance database for all patients undergoing implantable
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
TX & MCS
Cite this article as: Leidenfrost J, Prasad S, Itoh A, Lawrance C, Bell JM, Silvestry SC. Right ventricular assist device with membrane oxygenator support for right ventricular failure following implantable left ventricular assist device placement. Eur J Cardiothorac Surg 2015; doi:10.1093/ejcts/ezv116.
2
J. Leidenfrost et al. / European Journal of Cardio-Thoracic Surgery
cfLVAD from March 2009 to June 2013. The study protocol was approved by the Washington University Human Research Protection Office with a waiver for patient consent. RV failure requiring RVAD support was defined as patients who had inadequate cardiac output, elevated central venous pressure and poor LVAD filling despite maximal vasopressor, pulmonary vascular dilatation and inotropic therapy. The decision to implant is a multidisciplinary decision made by both the surgical and anaesthesia critical care teams (Fig. 1). During this time period, 267 cfLVADs were implanted, with 27 patients treated for perioperative RV failure by RVAD placement. RVADs were weaned per our protocol. We analysed survival at discharge, 3 months, 6 months and 1 year. RVADs utilized were 25 Centrimag (Thoratec, Pleasanton, CA, USA), 1 Impella LD (Abiomed, Inc., Danvers, MA, USA) (implanted retrograde through the pulmonary artery into the right ventricle) and 1 Abiomed 5000 (Abiomed, Inc., Danvers, MA, USA).
Right ventricular assist device implantation All devices are implanted through a median sternotomy incision. cfLVAD implantation is performed on cardiopulmonary bypass. The patient is then weaned from cardiopulmonary bypass with inotropes. In patients with poor RV function preoperatively or post-pump RV dysfunction, inhaled pulmonary vasodilators (epoprostenol and nitric oxide) are added and titrated for maximal effect. The cfLVAD revolutions per minute is increased under transoesophageal echocardiographic (TOE) guidance. In cases where cfLVAD flow continues to be low due to complete collapse of the LV chamber despite maximal inotropic and pulmonary
vasodilator support, RV mechanical support is added. Cannula selection varies with implanting surgeon variations in anatomy expected, and duration of device therapy. Venous cannulation is undertaken using a malleable 36-French venous cannula through the right atrial appendage, and typically arterial cannulation is performed using a 10-mm graft anastomosed to the main pulmonary artery. Patients are assessed for oxygenator placement in the RVAD circuit. Patients who receive RVAD-MO after cfLVAD receive an in-line Quadrox Oxygenator (Maquet, Rastatt, Germany) in the RVAD circuit. Cannulas are brought out subxiphoid and connected to the circuit. Patients are packed and the chest left open for refractory bleeding. Postoperatively, the activated clotting time (ACT) is allowed to normalize, platelet count is maintained at >150 000, and fibrinogen is kept at >200 mg/l and INR at
