Search

Background: Refractory end-stage pulmonary failure may benefit from extracorporeal life support (ECLS) as a bridge to lung transplantation. Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) has been recommended for patients who have failed conventional medical therapy and mechanical ventilation. Veno-arterial (VA) ECMO may be used in patients with acute right ventricular (RV) failure, haemodynamic instability, or refractory respiratory failure. Peripheral percutaneous approaches, either dual-site single-lumen cannulation for veno-pulmonary (VP) ECMO or single-site dual-lumen (dl)VP ECMO, using the ProtekDuo right ventricular assist device (RVAD) cannula, has made this configuration a desirable option as a bridge to transplantation. These configurations support the right ventricle, prevent recirculation by placing the tricuspid and pulmonary valve between the drainage and return cannulas, provide the direct introduction of oxygenated blood into the pulmonary artery, and have been shown to decrease the incidence of acute kidney injury (AKI), requiring continuous renal replacement therapy (CRRT) in certain disease states. This promotes haemodynamic stability, potential sedation-weaning trials, extubation, mobilisation, and pre-transplant rehabilitation. Methods: A web-based literature search in PubMed and EMBASE was undertaken based on a combination of keywords. The PICOS and PRISMA approaches were used. Results: Four case series were identified out of 323 articles, with a total of 34 patients placed on VP ECMO as a bridge to lung transplantation. All relevant data are reviewed and integrated into the Discussion. Conclusions: Despite the limited available evidence, the use of ProtekDuo has become very promising for the management of end-stage lung disease as a bridge to lung transplantation. [ABSTRACT FROM AUTHOR]

Right ventricular failure (RVF) is a clinical challenge associated with various underlying acute and chronic medical conditions, necessitating diverse management strategies including mechanical circulatory support (MCS). The ProtekDuo cannula represents an important advancement in medical devices for MCS in the setting of RVF. When combined with an extracorporeal blood pump, the dual-lumen design allows for direct bypass of the RV using simultaneous drainage and return of blood using percutaneous, single-site access. Studies have reported favorable outcomes with the ProtekDuo cannula and low device-related complications, but comparative studies with other MCS devices are limited. Still, the ProtekDuo cannula has numerous advantages; however, it is not without challenges, and opportunities for further research exist. The ProtekDuo cannula holds significant potential for future advancements in the field of MCS, offering promising solutions for RVF management. [ABSTRACT FROM AUTHOR]

The function of the right ventricle (RV) is to drive the forward flow of blood to the pulmonary system for oxygenation before returning to the left ventricle. Due to the thin myocardium of the RV, its function is easily affected by decreased preload, contractile motion abnormalities, or increased afterload. While various etiologies can lead to changes in RV structure and function, sudden changes in RV afterload can cause acute RV failure which is associated with high mortality. Early detection and diagnosis of RV failure is imperative for guiding initial medical management. Echocardiographic findings of reduced tricuspid annular plane systolic excursion (<1.7) and RV wall motion (RV S′ <10 cm/s) are quantitatively supportive of RV systolic dysfunction. Medical management commonly involves utilizing diuretics or fluids to optimize RV preload, while correcting the underlying insult to RV function. When medical management alone is insufficient, mechanical circulatory support (MCS) may be necessary. However, the utility of MCS for isolated RV failure remains poorly understood. This review outlines the differences in flow rates, effects on hemodynamics, and advantages/disadvantages of MCS devices such as intra-aortic balloon pump, Impella, centrifugal-flow right ventricular assist devices, extracorporeal membrane oxygenation, and includes a detailed review of the latest clinical trials and studies analyzing the effects of MCS devices in acute RV failure. • RV failure is difficult to diagnose. Utilization of laboratory values, imaging modalities, and various hemodynamic variables can aid in diagnosis. • Physicians should have a high index of suspicion and employ early mechanical support in the management of cardiogenic shock. • Multiple mechanical support devices are available and should be utilized in both isolated RV failure and biventricular failure when appropriate. [ABSTRACT FROM AUTHOR]

Pulmonary embolism (PE) is a common acute cardiovascular condition. Within this review, we discuss the incidence, pathophysiology, and treatment options for patients with high-risk and massive pulmonary embolisms. In particular, we focus on the role of mechanical circulatory support devices and their possible therapeutic benefits in patients who are unresponsive to standard therapeutic options. Moreover, attention is given to device selection criteria, weaning protocols, and complication mitigation strategies. Finally, we underscore the necessity for more comprehensive studies to corroborate the benefits and safety of MCS devices in PE management. [ABSTRACT FROM AUTHOR]

Fusion imaging (FI) technology using EchoNavigator that integrates live transesophageal echocardiogram and overlays on real‐time fluoroscopy. We present our experience placing a right ventricular (RV) support device, a ProtekDuo, in our patient with post‐operative RV failure using FI to guide the implantation. [ABSTRACT FROM AUTHOR]

Advances in mechanical circulatory support and changes in allocation policy have shifted waitlisting practices for heart transplantation (HT) in the United States. This analysis reports waitlist and transplant outcomes among HT candidates bridged with temporary endovascular right ventricular assist devices (tRVADs). Patients awaiting HT from 2008 to 2022 in the United Network of Organ Sharing registry were grouped by the presence of tRVAD while waitlisted and propensity matched. Waitlist outcomes were HT and a competing outcome of death/deterioration requiring waitlist inactivation. Competing-risks regression was used to model waitlist outcomes. Subanalyses were performed to compare waitlist outcomes among patients with durable and temporary left ventricular assist devices (LVADs) with and without concomitant tRVADs. One-year posttransplant mortality was estimated using Kaplan-Meier analysis. Of 41,507 HT candidates, 133 (0.3%) had tRVADs. After propensity matching, patients with tRVAD had a similar likelihood of HT and an elevated hazard for death/deterioration (hazard ratio 2.2, 95% confidence interval 1.4-3.2, p < 0.001) compared to those without tRVAD. Most patients with tRVAD (84%) had concomitant LVADs. tRVAD was associated with an elevated risk for deterioration/death among those with temporary LVADs but not durable LVADs. For patients undergoing HT, tRVAD was associated with an increased risk for 1-year mortality compared to propensity-matched recipients. Bridging with tRVAD is uncommon and primarily used in patients requiring biventricular support. tRVADs are associated with waitlist inactivation or death, particularly with concomitant temporary LVAD support. As temporary devices are increasingly used as a bridge to HT, outcomes of patients with tRVADs should inform future allocation policy, particularly for candidates with biventricular failure. [ABSTRACT FROM AUTHOR]

Purpose of Review: To describe medical therapies and mechanical circulatory support devices used in the treatment of acute right ventricular failure. Recent Findings: Experts have proposed several algorithms providing a stepwise approach to medical optimization of acute right ventricular failure including tailored volume administration, ideal vasopressor selection to support coronary perfusion, inotropes to restore contractility, and pulmonary vasodilators to improve afterload. Studies have investigated various percutaneous and surgically implanted right ventricular assist devices in several clinical settings. Summary: The initial management of acute right ventricular failure is often guided by invasive hemodynamic data tracking parameters of circulatory function with the use of pharmacologic therapies. Percutaneous microaxial and centrifugal extracorporeal pumps bypass the failing RV and support circulatory function in severe cases of right ventricular failure. [ABSTRACT FROM AUTHOR]

A 25-year-old female was presented with acute right heart failure (aRHF) and cardiogenic shock secondary to thyrotoxicosis with concomitant acute respiratory failure. A ProtekDuo cannula was placed to provide temporary percutaneous right ventricular assistance and extracorporeal membrane oxygenation (ECMO) in venopulmonary (V-P) configuration, which provided both decompression of the right ventricle (RV) and oxygenation. With treatment of the underlying thyrotoxicosis, the RV function improved and respiratory failure resolved. She was discharged home in good condition. This case details alternative ECMO management with ProtekDuo compared to the gold standard of venoarterial (V-A) ECMO. [ABSTRACT FROM AUTHOR]

Implantable left ventricular assist device (LVAD) is a state-of-the-art treatment for adults and children with end-stage heart failure. The early and late period after LVAD implantation can be severely complicated. Right ventricular failure (RVF) still remains a common complication after LVAD implantation. RVF is the cause of reduced post-implant survival. We suggest that an additional temporary or permanent right ventricular assist device (RVAD) is an effective treatment for LVAD-associated RVF. In this clinical case report, we describe the medical history of a pediatric patient (14 years old) with severe heart failure (PediMACS Level 1) against a background of dilated cardiomyopathy. The patient required peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) prior to urgent LVAD (HM3) implantation. In the early post-LVAD implantation (1 POD) period, the patient presented with hemodynamic and echocardiographic events of acute RVF that was resistant to drug therapy (inotropic/vasopressor support, iNO) and required mechanical circulatory support (MCS) with a preoperatively implanted VA-ECMO. In the LVAD-associated RVF scenario, VA-ECMO as a means of total cardiac bypass is a non-physiological MCS method and, therefore, undesirable. In this clinical situation, our solution was to use a paracorporeal centrifugal blood pump for temporary right heart support. A RVAD was assembled using percutaneous cannulation in two sites and a modification of the pre-existing VA-ECMO circuit. For RVAD, we used an ECMO cannula previously installed through the femoral vein (26 F) and added a reverse venous cannula (22 F) through the right internal jugular vein into the pulmonary trunk. To facilitate the passage of the return cannula into the pulmonary artery, we used a contralateral sheath (6 F, 40 cm) and an Amplatz Super Stiff guidewire under radiological control. The oxygenator was removed from the circuit on day 2 of RVAD. Central hemodynamics (reduction in right atrial pressure (RAP) to 10 mm Hg, increase in pulmonary capillary wedge pressure (PCWP) to 14 mm Hg), as well as right ventricular (RV) and left ventricular (LV) volume characteristics all improved. These observations allowed us to optimize the performance of the implantable LVAD (increase in flow rate to 4.2 l/min or 2.1 l/min/m2). The duration of paracorporeal RVAD after LVAD implantation was 7 days with an average flow rate of 2.3 ± 0.2 l/min. Postoperative treatment in the intensive care unit (ICU) lasted for 15 days. The patient was discharged from the hospital on postoperative day 34.

Abstract COVID–19 infection can lead to severe acute respiratory distress syndrome (ARDS), right ventricular (RV) failure and pulmonary hypertension. Venovenous extracorporeal membrane oxygenation (V-V ECMO) has been used for patients with refractory hypoxemia. More recently dual-lumen right atrium to pulmonary artery oxygenated right ventricular assist devices (Oxy-RVAD) have been utilized in the severe medical refractory COVID ARDS setting. Historically, animal data has demonstrated that high continuous non-pulsatile RVAD flows, leading to unregulated and unprotected circulation through the pulmonary vessels is associated with an increased risk of pulmonary hemorrhage and increased amount of extravascular lung water. These risks are heightened in the setting of ARDS with fragile capillaries, left ventricular (LV) diastolic failure, COVID cardiomyopathy, and anticoagulation. Concurrently, due to infection, tachycardia, and refractory hypoxemia, high V-V ECMO flows to match high cardiac output are often necessary to maintain systemic oxygenation. Increase in cardiac output without a concurrent increase in VV ECMO flow will result in a higher fraction of deoxygenated blood returning to the right heart and therefore resulting in hypoxemia. Several groups have suggested using a RVAD only strategy in COVID ARDS; however, this exposes the patients to the risk of pulmonary hemorrhage. We present one of the first known cases using an RV mechanical support, partial flow pulmonary circulation, oxygenated Veno-venopulmonary (V-VP) strategy resulting in RV recovery, total renal recovery, awake rehabilitation, and recovery.

The ProtekDuo, single site dual lumen cannula can be used in a multitude of configurations. In the medical literature, the ProtekDuo is described as right ventricular assist device (RVAD), as left ventricular assist device (LVAD), as biventricular assist device (BiVAD) when combined with an Impella device or other LVAD's, as double lumen drainage cannula on cardiopulmonary bypass (CPB), as RVAD with oxygenator, in veno-pulmonary (V-P) ECMO configuration, venovenous-pulmonary (VV-P) ECMO configuration with additional drainage cannula, and in veno-venopulmonary (V-VP) ECMO configuration as double lumen return cannula. Improvements in flow and oxygenation have been recognized in various settings and need further scientific evaluation. We summarized the above-mentioned configurations, technical aspects, and the present literature available for the ProtekDuo. [ABSTRACT FROM AUTHOR]

This article describes a case study where a patient with ProtekDuo + oxygenator and Impella CP (PROpella) in biventricular failure and cardiogenic shock was reconfigured to venopulmonary-arterial (VP-A) extracorporeal membrane oxygenation (ECMO), secondary to leg ischemia. The ProtekDuo was subsequently used as double-lumen drainage cannula, returning blood into a newly percutaneously placed femoral arterial cannula, mimicking venoarterial (V-A) ECMO in VP-A configuration. The following day, an Impella 5.5 could be placed and the ProtekDuo was reconfigured back to its default venopulmonary (V-P) ECMO configuration, now again as PROpella with minimally invasive biventricular groin-free full mechanical circulatory support. However, while in VP-A, good drainage blood flows of up to 4.5 LPM could be achieved similar to the ProtekDuo forward flow. None of the lumens collapsed secondary to negative pressure in the system. Drainage through the ProtekDuo for VP-A ECMO is feasible and without complications for a 24-hour period. This new method extends the ProtekDuo's spectrum of use. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Postcardiotomy RV dysfunction is an under‐recognized cause of acute kidney injury (AKI). Insertion of a percutaneous right ventricular assist device (RVAD) reduces central venous hypertension and congestive nephropathy by augmenting cardiac output. In selected patients, percutaneous RVAD insertion may improve renal function and obviate the need for long‐term dialysis. [ABSTRACT FROM AUTHOR]

A 25-year-old female was presented with acute right heart failure (aRHF) and cardiogenic shock secondary to thyrotoxicosis with concomitant acute respiratory failure. A ProtekDuo cannula was placed to provide temporary percutaneous right ventricular assistance and extracorporeal membrane oxygenation (ECMO) in venopulmonary (V-P) configuration, which provided both decompression of the right ventricle (RV) and oxygenation. With treatment of the underlying thyrotoxicosis, the RV function improved and respiratory failure resolved. She was discharged home in good condition. This case details alternative ECMO management with ProtekDuo compared to the gold standard of venoarterial (V-A) ECMO.

This article describes a case study where a patient with ProtekDuo + oxygenator and Impella CP (PROpella) in biventricular failure and cardiogenic shock was reconfigured to venopulmonary-arterial (VP-A) extracorporeal membrane oxygenation (ECMO), secondary to leg ischemia. The ProtekDuo was subsequently used as double-lumen drainage cannula, returning blood into a newly percutaneously placed femoral arterial cannula, mimicking venoarterial (V-A) ECMO in VP-A configuration. The following day, an Impella 5.5 could be placed and the ProtekDuo was reconfigured back to its default venopulmonary (V-P) ECMO configuration, now again as PROpella with minimally invasive biventricular groin-free full mechanical circulatory support. However, while in VP-A, good drainage blood flows of up to 4.5 LPM could be achieved similar to the ProtekDuo forward flow. None of the lumens collapsed secondary to negative pressure in the system. Drainage through the ProtekDuo for VP-A ECMO is feasible and without complications for a 24-hour period. This new method extends the ProtekDuo's spectrum of use.

Introduction: Acute right ventricular failure (aRVF) is associated with high mortality and morbidity. Mechanical circulatory support (MCS) may be considered as an advanced treatment option. The ProtekDuo is a cannula that can be used to provide acute right ventricular support as part of a temporary percutaneous (tp) right ventricular assist device (RVAD) system. The primary objective of this systematic review is to describe patient survival and complications when the ProtekDuo cannula was used as part of an tpRVAD system. Methods: MEDLINE, Embase, and Scopus were searched from database inception to August 26, 2022. Reference sections of studies were reviewed to screen for database omissions. Results: Seven studies with 127 patients were eligible for inclusion. The studies included patients with aRVF from a variety of causes. Mean duration of support was between 10 and 58 days in five studies. Patient survival to discharge was between 60% and 85.2% in two studies. Four authors reported 30-day survival between 60% and 85.2%. Devicerelated and non-device related complications were low. Conclusions: Patients treated with RVAD using the ProtekDuo cannula have comparable survival rates and complications to other tpRVAD systems. Several advantages exist compared to other RVAD systems. [ABSTRACT FROM AUTHOR]

COVID–19 infection can lead to severe acute respiratory distress syndrome (ARDS), right ventricular (RV) failure and pulmonary hypertension. Venovenous extracorporeal membrane oxygenation (V-V ECMO) has been used for patients with refractory hypoxemia. More recently dual-lumen right atrium to pulmonary artery oxygenated right ventricular assist devices (Oxy-RVAD) have been utilized in the severe medical refractory COVID ARDS setting. Historically, animal data has demonstrated that high continuous non-pulsatile RVAD flows, leading to unregulated and unprotected circulation through the pulmonary vessels is associated with an increased risk of pulmonary hemorrhage and increased amount of extravascular lung water. These risks are heightened in the setting of ARDS with fragile capillaries, left ventricular (LV) diastolic failure, COVID cardiomyopathy, and anticoagulation. Concurrently, due to infection, tachycardia, and refractory hypoxemia, high V-V ECMO flows to match high cardiac output are often necessary to maintain systemic oxygenation. Increase in cardiac output without a concurrent increase in VV ECMO flow will result in a higher fraction of deoxygenated blood returning to the right heart and therefore resulting in hypoxemia. Several groups have suggested using a RVAD only strategy in COVID ARDS; however, this exposes the patients to the risk of pulmonary hemorrhage. We present one of the first known cases using an RV mechanical support, partial flow pulmonary circulation, oxygenated Veno-venopulmonary (V-VP) strategy resulting in RV recovery, total renal recovery, awake rehabilitation, and recovery. [ABSTRACT FROM AUTHOR]

Right ventricular assist device (RVAD) weaning is often an important goal for durable left ventricular assist device support. This may be facilitated by mitral and tricuspid repair as well as by minimizing the trauma of RVAD decannulation by using Dacron grafts.

Key Clinical Message Postcardiotomy RV dysfunction is an under‐recognized cause of acute kidney injury (AKI). Insertion of a percutaneous right ventricular assist device (RVAD) reduces central venous hypertension and congestive nephropathy by augmenting cardiac output. In selected patients, percutaneous RVAD insertion may improve renal function and obviate the need for long‐term dialysis.

Acute right ventricular (RV) failure following massive pulmonary embolism (PE) can have significant hemodynamic consequences and is the mode of death. Temporary mechanical circulatory support can provide tissue perfusion required while thrombectomy or lysis‐aimed therapies act to relieve the thrombotic obstruction. Veno‐arterial extracorporeal membrane oxygenation (V‐A ECMO) has conventionally been the first line MCS. A more selective approach to RV support has been advocated in the form of an extracorporeal right ventricular assist device (RVAD) as it mitigates some of the shortcomings of V‐A ECMO. We present the first case series of four patients who received fully percutaneous RVAD, with an integrated oxygenator forming an Oxy‐RVAD, for selective right heart support following massive PE, including the application of single‐access dual‐lumen right atrium to pulmonary artery cannula. All patients achieved RV recovery and were successfully weaned from oxy‐RVAD support within 5–10 days demonstrating the feasibility of selective percutaneous right heart support in managing these challenging patients. [ABSTRACT FROM AUTHOR]

Severe right ventricular (RV) failure is associated with significant morbidity and mortality. Although right ventricular assist devices (RVADs) are increasingly used for refractory RV failure, there is limited data on their short- and long-term outcomes. Therefore, we undertook this study to better understand our experience with temporary RVADs. We conducted a retrospective review of all RVADS performed from 2017 to 2021. Patients supported with surgical RVADs, the Protek Duo device, and the Impella RP device were included. Patients were stratified by the type of RVAD and by etiology of RV failure. Survival was assessed by the Kaplan–Meier method and multivariable Cox proportional hazards regression models. From 2017 to 2021, 42 patients underwent RVAD implantation: 32 with a Protek Duo, 6 with an Impella RP, and 4 with a surgical RVAD. Majority of patients were already supported with an alternate form of mechanical support. Most patients had impaired renal function, decreased hepatic function, and lactic acidosis at the time of cannulation. The median duration of RVAD support was 8.5 [5-19] d. Survival to decannulation was 68.4%, to discharge was 47.4%, and to 1-y was 40.2%. Multivariable analysis identified elevated total bilirubin levels to be associated with 30-d mortality while increased hemoglobin levels were protective. After RVAD cannulation, the median number of pressors and inotropes was lower (P < 0.01) and the lactic acidosis was less (P < 0.01). In conclusion, RVAD support is associated with lower lactate levels, and decreased number of vasoactive medications, but is associated with significant morbidity and mortality. [ABSTRACT FROM AUTHOR]

Objectives: The main aim was a systematic evaluation of the current evidence on outcomes for patients undergoing right ventricular assist device (RVAD) implantation following left ventricular assist device (LVAD) implantation. Methods: This systematic review was registered on PROSPERO (CRD42019130131). Reports evaluating in-hospital as well as follow-up outcome in LVAD and LVAD/RVAD implantation were identified through Ovid Medline, Web of Science and EMBASE. The primary endpoint was mortality at the hospital stay and at follow-up. Pooled incidence of defined endpoints was calculated by using random effects models. Results: A total of 35 retrospective studies that included 3260 patients were analyzed. 30 days mortality was in favour of isolated LVAD implantation 6.74% (1.98–11.5%) versus 31.9% (19.78–44.02%) p = 0.001 in LVAD with temporary need for RVAD. During the hospital stay the incidence of major bleeding was 18.7% (18.2–19.4%) versus 40.0% (36.3–48.8%) and stroke rate was 5.6% (5.4–5.8%) versus 20.9% (16.8–28.3%) and was in favour of isolated LVAD implantation. Mortality reported at short-term as well at long-term was 19.66% (CI 15.73–23.59%) and 33.90% (CI 8.84–59.96%) in LVAD respectively versus 45.35% (CI 35.31–55.4%) p ⩽ 0.001 and 48.23% (CI 16.01–80.45%) p = 0.686 in LVAD/RVAD group respectively. Conclusion: Implantation of a temporary RVAD is allied with a worse outcome during the primary hospitalization and at follow-up. Compared to isolated LVAD support, biventricular mechanical circulatory support leads to an elevated mortality and higher incidence of adverse events such as bleeding and stroke. [ABSTRACT FROM AUTHOR]

Background: Over the past decade, several minimally invasive mechanical support devices have been introduced into clinical practice to support the right ventricle (RV). Percutaneous cannulas are easy to insert, minimally invasive, and treat acute RV failure rapidly. In December 2021, the Food and Drug Administration approved a new 31 French dual lumen single cannula for use as a right ventricular assist device.Aims: Descirbe the use of the new dual lumen percutaneous right ventricular assist device (RVAD) cannula.Material and Methods: Deployment of the RVAD can be done surgically or percutaneously. This cannula, manufactured by Spectrum, is dual staged. It has inflow ports positioned both in the right atrium (RA) as well as the RV for maximal drainage of the right heart. The distal end of the cannula which includes the outflow port is positioned in the pulmonary artery (PA).Results: Deployment of the Spectrum RVAD can be done percutaneously with transesophageal and flouroscopy guidence. Cannulation requires requisite wire skills in order to navigate into the main pulmonary artery. Utilization of this cannula can be done in acute RV failure secondary to ischemia, post cardiotomy shock, acute respiratory failure or other causes of isolated RV failure.Discussion: The dual stage drainage design optimizes venous drainage as well as limits suck-down events. Theoretically, direct RV decompression also decreases RV dilation and wall tension, and facilitates improved transmural pressure gradient to reduce RV strain.Conclusion: Here we describe the first-in-man successful use of the dual-stage RA and RV to PA Spectrum cannula in a patient with severe COVID acute respiratory distress syndrome and acute right ventricular failure, bridged to recovery. [ABSTRACT FROM AUTHOR]

Competing Interests: Declaration of competing interest The authors declare no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

The article discusses the importance of adhering to standardized nomenclature in the field of extracorporeal life support (ECLS), specifically focusing on the venopulmonary extracorporeal membrane oxygenation (ECMO) mode. The authors highlight the need for consistent terminology and abbreviations to improve communication and reduce ambiguity in scientific publications. They argue that the adoption of standardized nomenclature has been slow and call for journals to promote the use of the nomenclature developed by the Extracorporeal Life Support Organization (ELSO). The authors acknowledge their oversight in using inconsistent terminology in their own article and express agreement with the need for adherence to standardized nomenclature. [Extracted from the article]

Often labeled the forgotten ventricle, the right ventricle's (RV) importance has been magnified over the last 2 years as providers witnessed how severe acute respiratory syndrome coronavirus 2 infection has a predilection for exacerbating RV failure. Venovenous extracorporeal membranous oxygenation (VV-ECMO) has become a mainstay treatment modality for a select patient population suffering from severe COVID-19 acute respiratory distress syndrome. Concomitant early implementation of a right ventricular assist device with ECMO (RVAD-ECMO) may confer benefit in patient outcomes. The underlying mechanism of RV failure in COVID-19 has a multifactorial etiopathogenesis; nonetheless, clinical evaluation of a patient necessitating RV support remains unchanged. Herein, the authors report the case of a critically ill patient who was transitioned from a conventional VV-ECMO Medtronic Crescent cannula to RVAD-ECMO, with the insertion of the LivaNova ProtekDuo dual-lumen RVAD cannula. [ABSTRACT FROM AUTHOR]

We present a case of acute respiratory distress syndrome (ARDS) secondary to COVID-19 who required venovenous extracorporeal membrane oxygenation (V-V ECMO). Initially, a right ventricular assist device (RVAD), the ProtekDuo with an oxygenator, was placed in an outside heart center and the patient was transferred to us for ECMO management. Due to severe hypoxia, the configuration was later modified, and a 25 Fr femoral drainage cannula was inserted for venous drainage only. The arterial return tubing was spliced and using a Y-connector, arterialized blood was returned through both limbs of the ProtekDuo resulting in a significantly increased oxygenation and flow.

The importance of right heart failure (RHF) treatment is magnified over the years due to the increased risk of mortality. Additionally, the multifactorial origin and pathophysiological mechanisms of RHF render this clinical condition and the choices for appropriate therapeutic target strategies remain to be complex. The recent change in the United Network for Organ Sharing (UNOS) allocation criteria of heart transplant may have impacted for the number of left ventricular assist devices (LVADs), but LVADs still have been widely used to treat advanced heart failure, and 4.1 to 7.4% of LVAD patients require a right ventricular assist device (RVAD). In addition, patients admitted with primary left ventricular failure often need right ventricular support. Thus, there is unmet need for temporary or long-term support RVAD implantation exists. In RHF treatment with mechanical circulatory support (MCS) devices, the timing of the intervention and prediction of duration of the support play a major role in successful treatment and outcomes. In this review, we attempt to describe the prevalence and pathophysiological mechanisms of RHF origin, and provide an overview of existing treatment options, strategy and device choices for MCS treatment for RHF.

Right heart output in heart failure can be compensated through increasing systemic venous pressure. We determined whether the magnitude of this "passive cardiac output" can predict LVAD outcomes. This was a retrospective review of 383 patients who received a continuous-flow LVAD at the University of Michigan between 2012 and 2021. Pre-LVAD cardiac output driven by venous pressure was determined by dividing right atrial pressure by mean pulmonary artery pressure, multiplied by total cardiac output. Normalization to body surface area led to the passive cardiac index (PasCI). The Youden J statistic was used to identify the PasCI threshold, which predicted LVAD death by 2 years. Increased preoperative PasCI was associated with reduced survival (hazard ratio [HR], 2.27; P <.01), and increased risk of right ventricular failure (RVF) (HR, 3.46; P =.04). Youden analysis showed that a preoperative PasCI ≥0.5 (n = 226) predicted LVAD death (P =.10). Patients with PasCI ≥0.5 had poorer survival (P =.02), with a trend toward more heart failure readmission days (mean, 45.09 ± 67.64 vs 35.13 ± 45.02 days; P =.084) and increased gastrointestinal bleeding (29.2% vs 20.4%; P =.052). Additionally, of the 97 patients who experienced readmissions for heart failure, those with pre-LVAD implantation PasCI ≥0.5 were more likely to have more than 1 readmission (P =.05). Although right heart output can be augmented by raising venous pressure, this negatively impacts end-organ function and increases heart failure readmission days. Patients with a pre-LVAD PasCI ≥0.5 have worse post-LVAD survival and increased RVF. Using the PasCI metric in isolation or incorporated into a predictive model may improve the management of LVAD candidates with RV dysfunction. [Display omitted] [ABSTRACT FROM AUTHOR]

Right ventricular heart failure (RVHF) is a critical complication in patients with respiratory failure, particularly among those who transitioned to lung transplantation using venovenous (VV) extracorporeal membrane oxygenation (ECMO). In these patients, both cardiac and respiratory functions are supported using venoarterial or venoarterial-venous ECMO. However, these modalities increase the risk of device-related complications, such as thromboembolism, bleeding, and limb ischemia, and they may disturb early rehabilitation. Due to these limitations, a right ventricular assist device with an oxygenator (Oxy-RVAD) using ECMO may be considered for patients with RVHF with VV ECMO. A retrospective case series and literature review. A single tertiary care university hospital. The study comprised lung transplantation candidates on ECMO bridging who developed right-sided heart failure. An RVAD with ECMO. Of eight patients who underwent the study protocol, seven were bridged successfully to lung transplantation (BTT), and all patients with BTT were discharged, with a 30-day survival rate of 100% (7/7 patients). The 180-day survival rate was 85% (6/7 patients). The study suggested that Oxy-RVAD using ECMO may be a viable option for bridging patients with RVHF to lung transplantation. Retrospectively registered. [ABSTRACT FROM AUTHOR]

Given the increased need for mechanical circulatory support and subsequent development of right ventricular assist devices (RVAD), appropriate imaging needs to be described to facilitate care in patients with cardiogenic shock and heart failure. We present three cases in which the upper esophageal aortic arch short axis (UE AA SAX) view on transesophageal echocardiography (TEE) was utilized to effectively image RVADs: to confirm normal positioning, to detect and guide repositioning, and to visualize malfunction. These cases support the importance of the UE AA SAX TEE view in RVAD outflow imaging and, when obtainable, should be included in routine RVAD assessment. [ABSTRACT FROM AUTHOR]

Background Impella RP (Abiomed, Danvers, MA, USA) is indicated for right ventricular failure after left ventricular assist device insertion or biventricular shock. Once the peel-away sheath is removed, Impella RP repositioning can only be achieved with manual manipulation of the catheter itself. This method does not always accomplish appropriate positioning of the catheter and can result in continued haemodynamic instability. Case summary A young male presented to our institution with recurrent ventricular fibrillation and ST-elevation myocardial infarction that underwent emergent coronary intervention but was in progressive cardiogenic shock requiring implantation of Impella 5.0 and Impella RP. After insertion of the right ventricular support, the patient stabilized transiently then became unstable once more, and repeat fluoroscopy demonstrated that the Impella RP had 'fallen back' into the right ventricle. Due to continued instability, we improvised a previously undescribed method of repositioning of the Impella RP catheter with the use of a goose-neck snare. Discussion The snare–manoeuvre–prolapse method of Impella RP repositioning is a relatively novel approach at the management of Impella RP retrograde migration into the right ventricle and prevents the need for large-bore venous closure and re-access and the use of a new Impella RP catheter while providing rapid improvement of haemodynamics. [ABSTRACT FROM AUTHOR]

There is little insight into which patients can be weaned off right ventricular (RV) acute mechanical circulatory support (AMCS) after left ventricular assist device (LVAD) implantation. We hypothesize that concomitant RV AMCS insertion instead of postoperative implantation will improve 1-year survival and increase the likelihood of RV AMCS weaning. A multicenter retrospective database of 826 consecutive patients who received a HeartMate II or HVAD between January 2007 and December 2016 was analyzed. We identified 91 patients who had early RV AMCS on index admission. Cox proportional-hazards model was constructed to identify predictors of 1-year mortality post-RV AMCS implantation and competing risk modeling identified RV AMCS weaning predictors. There were 91 of 826 patients (11%) who required RV AMCS after CF-LVAD implantation with 51 (56%) receiving a concomitant RV AMCS and 40 (44%) implanted with a postoperative RV AMCS during their ICU stay; 48 (53%) patients were weaned from RV AMCS support. Concomitant RV AMCS with CF-LVAD insertion was associated with lower mortality (HR 0.45 [95% CI 0.26-0.80], p = 0.01) in multivariable model (which included age, BMI, angiotensin-converting enzyme inhibitor use, and heart transplantation as a time-varying covariate). In the multivariate competing risk analysis, a TPG < 12 (SHR 2.19 [95% CI 1.02-4.70], p = 0.04) and concomitant RV AMCS insertion (SHR 3.35 [95% CI 1.73-6.48], p < 0.001) were associated with a successful wean. In patients with RVF after LVAD implantation, concomitant RV AMCS insertion at the time of LVAD was associated with improved 1-year survival and increased chances of RV support weaning compared to postoperative insertion. [ABSTRACT FROM AUTHOR]

Abstract Post‐operative right coronary artery occlusion is a serious complication that demands acute coronary revascularization to prevent myocardial infarction. We present two cases with acute right coronary artery obstruction caused by (1) transfemoral aortic valve implantation and (2) acute type A aortic dissection. Although coronary artery bypass grafting was performed intraoperatively, right heart failure was observed in both cases. The Impella RP® device offers temporary right ventricular mechanical support; wherefore, we decided to deploy it in both patients. The devices were uneventfully and successfully implanted to bridge for recovery of the right heart. We report the perioperative course of the patients as well as their condition at 1 year follow‐up.

Right ventricular failure (RVF) is a common complication that occurs after a left ventricular assist device (LVAD) is implanted. We report an interesting case of severe and refractory hypoxia during the early postoperative period after HeartMate3 (HM3) (Abbott Laboratories, Lake Forest, IL) implantation resulting in the unmasking of a right-to-left intracardiac shunt through a patent foramen ovale (PFO), triggered by early RVF. Importantly, the patient had a small left-to-right shunt after receiving a left-sided Impella 5.5 micro-axial pump (Abiomed, Danvers, MA, USA) pre-LVAD implantation. We observed improved hypoxia but worsening RVF after percutaneous PFO closure, necessitating right-sided mechanical circulatory support. We outline potential reasons for the significant PFO-related shunting seen after HM3 implantation, but not after Impella 5.5 placement. Uncertainty exists regarding the approach to a PFO in patients undergoing LVAD implantation. We propose an approach based on existing literature., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Pillai et al.)

Background: Right ventricular failure is an underrecognized consequence of COVID-19 pneumonia. Those with severe disease are treated with extracorporeal membrane oxygenation (ECMO) but with poor outcomes. Concomitant right ventricular assist device (RVAD) may be beneficial. Methods: A retrospective analysis of intensive care unit patients admitted with COVID-19 ARDS (Acute Respiratory Distress Syndrome) was performed. Nonintubated patients, those with acute kidney injury, and age > 75 were excluded. Patients who underwent RVAD/ECMO support were compared with those managed via invasive mechanical ventilation (IMV) alone. The primary outcome was in-hospital mortality. Secondary outcomes included 30-d mortality, acute kidney injury, length of ICU stay, and duration of mechanical ventilation. Results: A total of 145 patients were admitted to the ICU with COVID-19. Thirty-nine patients met inclusion criteria. Of these, 21 received IMV, and 18 received RVAD/ECMO. In-hospital (52.4 versus 11.1%, P = 0.008) and 30-d mortality (42.9 versus 5.6%, P = 0.011) were significantly lower in patients treated with RVAD/ECMO. Acute kidney injury occurred in 15 (71.4%) patients in the IMV group and zero RVAD/ECMO patients (P < 0.001). ICU (11.5 versus 21 d, P = 0.067) and hospital (14 versus 25.5 d, P = 0.054) length of stay were not significantly different. There were no RVAD/ECMO device complications. The duration of mechanical ventilation was not significantly different (10 versus 5 d, P = 0.44). Conclusions: RVAD support at the time of ECMO initiation resulted in the no secondary end-organ damage and higher in-hospital and 30-d survival versus IMV in specially selected patients with severe COVID-19 ARDS. Management of severe COVID-19 ARDS should prioritize right ventricular support. [ABSTRACT FROM AUTHOR]

Right ventricular dysfunction presents unique challenges in patients with cardiopulmonary disease. When optimal medical therapy fails, mechanical circulatory support is considered. Devices can by classified according to whether they are deployed percutaneously or surgically, whether the pump is axial or centrifugal, whether the right ventricle is bypassed directly or indirectly, and whether the support is short term or long term. Each device has advantages and disadvantages. Acute mechanical circulatory support is a suitable temporizing strategy in advanced heart failure. Future research in right ventricular mechanical circulatory support will optimize device management, refine patient selection, and ultimately improve clinical outcomes. [ABSTRACT FROM AUTHOR]

We present a case of acute respiratory distress syndrome (ARDS) secondary to COVID-19 who required venovenous extracorporeal membrane oxygenation (V-V ECMO). Initially, a right ventricular assist device (RVAD), the ProtekDuo with an oxygenator, was placed in an outside heart center and the patient was transferred to us for ECMO management. Due to severe hypoxia, the configuration was later modified, and a 25 Fr femoral drainage cannula was inserted for venous drainage only. The arterial return tubing was spliced and using a Y-connector, arterialized blood was returned through both limbs of the ProtekDuo resulting in a significantly increased oxygenation and flow. [ABSTRACT FROM AUTHOR]

Rescuing patients with the development of acute respiratory distress syndrome and right heart failure after left ventricular assist device placement remains a challenge in patients with congenital heart disease. TandemLife Protek Duo (TandemLife, Pittsburg, PA) is a double-lumen cannula introduced via the internal jugular vein that can provide veno-venous extra-corporeal membrane oxygenation and right heart support. To our knowledge, we report the first case of successfully using the TandemLife Protek Duo cannula to provide veno-venous extra-corporeal membrane oxygenation and right ventricle support in an adolescent male with an existing right ventricle-pulmonary artery conduit and the melody pulmonary valve who developed severe acute respiratory distress syndrome after the placement of left ventricular assist device. The stability of the cannula enabled minimal recirculation-related hypoxia events, early mobilization, and ambulation. Our patient was discharged home after lung recovery and currently awaiting a heart transplant. [ABSTRACT FROM AUTHOR]

Percutaneous mechanical thrombectomy devices have revolutionized the treatment of massive pulmonary embolism (PE) by providing a rapid, non-thrombolytic based method to re-establish right-sided circulation while reducing bleeding complications. However, with massive PE, the acute increase in right ventricular afterload results in a compounded hemodynamic compromise, which may necessitate the need for advanced cardiac support. This case exemplifies the need for a comprehensive and synergistic approach to the management of massive PE. To our knowledge, this is the first report of combination therapy using large bore mechanical suction thrombectomy (FlowTriever, INARI Medical, Irvine, CA, USA) in conjunction with the implantation of right ventricular mechanical support (Impella RP, ABIOMED, Danvers, MA, USA) in an effort to reverse the right ventricular "shock spiral." < Learning objective: To understand the importance of timely intervention in massive pulmonary embolism (PE) and the role of percutaneous mechanical thrombectomy devices in such situations where thrombolysis fails or is contraindicated. To incorporate the simultaneous use of mechanical circulatory support in the setting of massive PE.> [ABSTRACT FROM AUTHOR]