Right ventricular dysfunction after left ventricular assist device implantation
Authors:
H. Říha 1,4; I. Netuka 2,4; T. Kotulák 1; J. Malý 2,4; M. Pinďák 1; P. Kellovský 1; F. Kopáč 1; D. Hodr 1; O. Szárszoi 2,4; J. Kettner 3; H. Al-Hiti 2; Z. Dorazilová 3; T. Marek 3; I. Skalský 2; J. Pirk 2,4
Authors‘ workplace:
Klinika anesteziologie a resuscitace, Kardiocentrum IKEM Praha, přednosta prim. MUDr. Tomáš Kotulák
1; Klinika kardiovaskulární chirurgie, Kardiocentrum IKEM Praha, přednosta prof. MUDr. Jan Pirk, DrSc.
2; Klinika kardiologie, Kardiocentrum IKEM Praha, přednosta prof. MUDr. Josef Kautzner, CSc.
3; Centrum výzkumu chorob srdce a cév IKEM Praha, vedoucí projektu prof. MUDr. Bohuslav Ošťádal, DrSc.
4
Published in:
Vnitř Lék 2010; 56(1): 30-36
Category:
Original Contributions
Overview
Objective:
The frequency of long‑term left ventricular assist device (LVAD) implantation is increasing. Acute right ventricular dysfunction or right ventricular failure after LVAD implantation has important influence on morbidity and mortality. The aim of our study was to assess the management of right ventricular dysfunction after LVAD implantation.
Methods:
The study group comprised 21 patients with implanted HeartMate II® LVAD since December, 2006 to April, 2009. We evaluated in retrospective fashion baseline parameters of cardiovascular and other organ systems before LVAD implantation, applied pharmacological and mechanical support for the right ventricle, and important clinical outcomes to the end of June, 2009.
Results:
LVAD was implanted in 18 men and 3 women with mean age of 48.7 ± 11.2 years. The most frequent diagnosis was dilatational cardiomyopathy (9 patients; 42.9%), and the most frequent indication for implantation was bridge-to-transplantation (19 patients; 90.4%). Pharmacological support of the right ventricle after LVAD implantation comprised dobutamine (21 patients; 100%), milrinone (21 patients; 100%), isoproterenol (1 patient; 4.8%), and levosimendan (5 patients; 23.8%). In 2 (9.5%) cases there was a need for repeated application of levosimendan during postoperative course. Inhalational nitric oxide was used in 14 (66.7%) patients. Despite extensive pharmacological support, 3 (14.3%) patients needed right ventricular assist device (RVAD) implantation. Most patients (9; 42.8%) survived to heart transplantation; in one (4.8%) case LVAD was successfuly explanted; 6 (28.6%) patients is living with LVAD; 5 (23.8%) patients died during LVAD support.
Conclusion:
After LVAD implantation there is a need for aggressive pharmacological, and in some cases mechanical, support of the right ventricular function to provide adequate blood flow to LVAD in order to minimize morbidity and mortality.
Key words:
mechanical circulatory support – right ventricular dysfunction – levosimendan – nitric oxide
Sources
1. Augoustides JG, Říha H. Recent progress in heart failure treatment and heart transplantation. J Cardiothorac Vasc Anesth 2009; 23: 738–748.
2. Netuka I, Malý J, Szarszoi O. Mechanické srdeční podpory v terapii terminálního srdečního selhání. Cor Vasa 2008; 50: 207–214.
3. Rose EA, Gelijns AC, Moskowitz AJ et al. Long‑term mechanical left ventricular assistance for end‑stage heart failure. N Engl J Med 2001; 345: 1435–1443.
4. Březina A, Říha H, Mašín J. Současné možnosti mechanické podpory cirkulace. Anest Intenziv Med 2006; 17: 38–44.
5. Kettner J, Netuka I, Pirk J et al. První použití mechanické srdeční podpory v České republice. Interv Akut Kardiol 2004; 3: 86–88.
6. Kettner J, Pirk J, Netuka I et al. Použití mechanické srdeční podpory – první zkušenosti v České republice. Čas Lék Čes 2005; 144: 38–42.
7. Struber M, Sander K, Lahpor J et al. HeartMate II left ventricular assist device; early European experience. Eur J Cardiothorac Surg 2008; 34: 289–294.
8. Dang NC, Topkara VK, Mercando M et al. Right heart failure after left ventricular assist device implantation in patients with chronic congestive heart failure. J Heart Lung Transplant 2006; 25: 1–6.
9. Netuka I, Malý J, Szarszoi O et al. Single‑stage extensive chronic type A dissecting aortic aneurysm repair and continuous‑flow ventricular assist device implantation. J Heart Lung Transplant 2009; 28: 523–526.
10. Haddad F, Couture P, Tousignant C et al. The right ventricle in cardiac surgery, a perioperative perspective: I. Anatomy, physiology, and assessment. Anesth Analg 2009; 108: 407–421.
11. Greyson CR. Pathophysiology of right ventricular failure. Crit Care Med 2008; 36: S57–S65.
12. Haddad F, Couture P, Tousignant C et al. The right ventricle in cardiac surgery, a perioperative perspective: II. Pathophysiology, clinical importance, and management. Anesth Analg 2009; 108: 422–433.
13. Stone ME. Current status of mechanical circulatory assistance. Semin Cardiothorac Vasc Anesth 2007; 11: 185–204.
14. Santamore WP, Gray LA Jr. Left ventricular contributions to right ventricular systolic function during LVAD support. Ann Thorac Surg 1996; 61: 350–356.
15. Omoto T, Tanabe H, LaRia PJ et al. Right ventricular performance during left ventricular unloading conditions: the contribution of the right ventricular free wall. Thorac Cardiovasc Surg 2002; 50: 16–20.
16. Klima UP, Lee MY, Guerrero JL et al. Determinants of maximal right ventricular function: role of septal shift. J Thorac Cardiovasc Surg 2002; 123: 72–80.
17. Saleh S, Liakopoulos OJ, Buckberg GD. The septal motor of biventricular function. Eur J Cardiothorac Surg 2006; 29 (Suppl 1): S126–S138.
18. Aaronson KD, Patel H, Pagani FD. Patient selection for left ventricular assist device therapy. Ann Thorac Surg 2003; 75: S29–S35.
19. Fitzpatrick JR 3rd, Frederick JR, Hiesinger W et al. Early planned institution of biventricular mechanical circulatory support results in improved outcomes compared with delayed conversion of a left ventricular assist device to a biventricular assist device. J Thorac Cardiovasc Surg 2009; 137: 971–977.
20. Ochiai Y, McCarthy PM, Smedira NG et al. Predictors of severe right ventricular failure after implantable left ventricular assist device insertion: analysis of 245 patients. Circulation 2002; 106: I198–I202.
21. Matthews JC, Koelling TM, Pagani FD et al. The right ventricular failure risk score a pre‑operative tool for assessing the risk of right ventricular failure in left ventricular assist device candidates. J Am Coll Cardiol 2008; 51: 2163–2172.
22. Weitkemper HH, El‑Banayosy A, Arusoglu L et al. Mechanical circulatory support: reality and dreams experience of a single center. J Extra Corpor Technol 2004; 36: 169–173.
23. Chumnanvej S, Wood MJ, MacGillivray TE et al. Perioperative echocardiographic examination for ventricular assist device implantation. Anesth Analg 2007; 105: 583–601.
24. Špinar J, Vítovec J. Intravenózní léčba akutního srdečního selhání. Vnitř Lék 2007; 53: 412–419.
25. Nussmeier NA, Probert CB, Hirsch D et al. Anesthetic management for implantation of the Jarvik 2000 left ventricular assist system. Anesth Analg 2003; 97: 964–971.
26. Missant C, Rex S, Segers P et al. Levosimendan improves right ventriculovascular coupling in a porcine model of right ventricular dysfunction. Crit Care Med 2007; 35: 707–715.
27. Kasikcioglu HA, Uyarel H, Tartan Z et al. Do calcium sensitizers affect right ventricular functions in patients with chronic heart failure? Int J Cardiol 2007; 118: 246–248.
28. Kerbaul F, Gariboldi V, Giorgi R et al. Effects of levosimendan on acute pulmonary embolism‑induced right ventricular failure. Crit Care Med 2007; 35: 1948–1954.
29. Kavarana MN, Pessin‑Minsley MS, Urtecho J et al. Right ventricular dysfunction and organ failure in left ventricular assist device recipients: a continuing problem. Ann Thorac Surg 2002; 73: 745–750.
30. Komoda T, Hetzer R, Lehmkuhl HB. Destiny of candidates for heart transplantation in the Eurotransplant heart allocation system. Eur J Cardiothorac Surg 2008; 34: 301–306.
31. Patel ND, Weiss ES, Schaffer J et al. Right heart dysfunction after left ventricular assist device implantation: a comparison of the pulsatile HeartMate I and axial‑flow HeartMate II devices. Ann Thorac Surg 2008; 86: 832–840.
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