Upfront BiVAD Support Over Salvage in Right Heart Failure after LVAD; When Two is Better than One
Presenter
Ben Borokhovsky, MD, Lehigh Valley Health Network, Allentown, PA
Ben Borokhovsky, MD and Nael Hawwa, MD, Lehigh Valley Health Network, Allentown, PA
Title
Upfront BiVAD Support Over Salvage in Right Heart Failure after LVAD; When Two is Better than One
Introduction
Left ventricular assist devices (LVAD) have emerged as a sustainable option in patients with end-stage cardiomyopathy for improving survival and quality of life. However, right heart failure (RHF) after LVAD implantation remains a major complication. The presence of RHF after LVAD implantation is associated with a higher mortality. Current management options are limited. The conventional approach is starting with pharmacotherapy and adjusting LVAD speed and, if refractory, escalation to mechanical circulatory support (MCS). However, in some instances, upfront RV MCS may prevent the vicious cycle of RHF and its associated complications.
Clinical Case
A 53-year-old male with nonischemic cardiomyopathy that progressed to inotrope dependence one month post-diagnosis presented a few months later in low output heart failure requiring temporary LV mechanical support (Impella 5.0). Due to psycho-social concerns, transplant was not an option. Given the acuity of his disease and lack of time to observe psycho-social improvements, LVAD was planned.
Despite four days of LV unloading and aggressive diuresis (>20L), his RV hemodynamics were improved but not ideal. Generally, having a RA:PCWP ratio greater than 0.5, elevated transaminases, bilirubin, and creatinine all portend a higher risk of RHF after LVAD implantation. His most optimal hemodynamics were RA 11-13, RA:PCWP 0.6, PAPI 0.8-1.2, thankfully, his biochemical parameters were acceptable. Given his risk for acute post-op RV failure, intra-operatively, he underwent an extracorporeal RVAD (CentriMag) in addition to LVAD (HeartMate-3).
He remained dependent on RVAD support for 3 weeks without a viable long-term option such as transplant. Thankfully, this prevented acute kidney injury and hepatic congestion. The goal was to maintain MCS until the RV was fully decongested and optimize the LVAD. This was achieved with 4 weeks of milrinone, sildenafil, aggressive de-congestion, and lowering LVAD speed to 4,700 rpm. With these low speeds, he required more aggressive afterload reduction given the H-Q curves. Despite an RV fractional area change of less than 5%, he was optimized with the above measures and discharged without milrinone. His RV eventually normalized 1.5 years later without any admissions for RV failure.
Discussion
It is crucial to recognize the warning signs of patients at risk of RHF after LVAD implantation. There is no definitive predictive system for RHF, therefore it is necessary to utilize the entire context when evaluating these patients. Some of these factors include their hemodynamics, echocardiographic findings, and biochemical markers. RV MCS should be considered upfront in these patients as opposed to salvage prior to their development of renal failure, liver failure, and vasoplegia. This also emphasizes the need for patients to go into LVAD surgery with the most ideal hemodynamics, and in the era of axillary Impella 5.5 this can be used for optimization with low risk of hemolysis.
Acute RHF post LVAD is best managed by predicting and recognizing the condition intra-operatively, and using upfront RVAD support as opposed to salvage. Prompt identification and management with upfront BiVAD support reduces RHF and its associated end-organ damage.