Temporary Right Heart Support Following LVAD Implantation in High Risk Patients with Dual Mechanical Support Combining Veno-arterial ECLS and Impella Microaxial Pump

Objectives: Dual mechanical support combining veno-arterial (VA) ECLS and Impella microaxial pump rescues high-risk patients in refractory cardiogenic shock and biventricular failure. An implantation of a permanent ventricular assist device (VAD) is a life-saving procedure for these patients if cardiac function does not recover under biventricular unloading. However, many questions centering on perioperative right heart failure (RHF) and stabilization of right ventricular function remain elusive. Here, we compared continuation of common VA ECLS via femoral access with a transvenous implantation technique of a temporary right heart bypass (RHB) for patients undergoing LVAD implantation after dual mechanical support.

Methods: We analyzed the results of patients undergoing LVAD implantation after successful bridging with dual mechanical support jointly using VA ECLS combined with Impella microaxial pump between March 2013 and June 2017. For perioperative stabilization of right heart function, patient group 1 was kept on common VA ECLS after LVAD implantation. Group 2 received a common ECLS circuit and transvenously implanted cannulas. The outflow cannula was implanted via the femoral vein placed for drainage in the right atrium. The 15French Bio-Medicus inflow cannula was inserted via the right jugular vein and placed in the pulmonary artery (PA).

Results: Twenty-four patients (male n = 19; median age 56 year; range 17–70) with refractory cardiogenic shock required biventricular mechanical support as a bridge-to-LVAD. The mean time on ECLS therapy was 8 days; range 0–49 days. The mean time on Impella microaxial pump was 6 days; range 1–15 days. In group 1 (n = 18) the VA ECLS therapy was continued in eighteen patients (75%) after LVAD implantation. The mean time on the VA ECLS after LVAD was 7 days; range 1–21. Within this group twelve patients died (67%) and six patients survived (33%). Group 2 (n = 6) received a temporary percutaneous RHB during LVAD implantation. The mean time on RHB was 8 days; range 4–18. In this group one patient died (17%) and five survived (83%).

Conclusion: In conclusion, high risk patients with refractory cardiogenic shock and double mechanical support via VA- ECMO and Impella microaxial pump can be bridged successfully to a LVAD implantation. For stabilization of the perioperative right heart function a percutaneously installed transvenous RHB seems to provide better outcomes compared with patients with continuation of the VA ECLS.