Experience with right ventricular assist devices for perioperative right-sided circulatory failure.

BACKGROUND

Right-sided circulatory failure remains a significant source of morbidity and mortality for both cardiac transplant and left ventricular assist device recipients.

METHODS

We reviewed our experience with 11 patients who required a right ventricular assist device (RVAD) after either orthotopic heart transplantation or left ventricular assist device implantation. Variables analyzed included total time of RVAD support, hemodynamic and hematologic parameters, and parameters of end-organ perfusion. These were assessed at five time points: (1) at least 2 weeks before RVAD implantation, (2) intraoperatively just before RVAD insertion, (3) while on RVAD support, and, for those who survived, (4) just before RVAD explantation, and (5) off RVAD support. Survival was assessed as the ability to be weaned successfully from RVAD support. Urine output and serum transaminase levels were recorded throughout the period of RVAD support.

RESULTS

Five patients received an ABIOMED 5000 BVS RVAD, and 6 received a Bio-Medicus centrifugal pump. Nine patients in the study underwent orthotopic heart transplantation and had development of right-sided circulatory failure from 0 to 96 hours after donor organ insertion, and 2 patients underwent left ventricular assist device implantation 12 to 48 hours before RVAD support. The mean time of RVAD support for survivors was 133.6 +/- 33.6 hours (range, 107 to 190 hours). Six patients were successfully separated from RVAD support, and 5 patients died while on RVAD support. Causes of death included sepsis (2), biventricular failure (2), and coagulopathy (1). Continuous arteriovenous hemodialysis was employed in 3 of 6 survivors and 1 of 5 nonsurvivors.

CONCLUSIONS

Right ventricular assist devices work most effectively if implanted early enough to avoid significant, potentially irreversible end-organ injury. We liberally employ continuous arteriovenous hemodialysis, minimize the use of heparin immediately postoperatively, keep patients sedated, and continue RVAD support until the patient displays signs of hemodynamic and end-organ recovery as heralded by (1) a decrease in central venous pressure and, more importantly, a decrease in pulmonary artery diastolic pressure, (2) an increase in urine output, and (3) a decrease in serum transaminase levels.