Centrifugal pump as right ventricular assist pump in the treatment of right ventricular failure following resection of left atrial myxoma

A 31-year-old woman had a left atrial myxoma associated with severe pulmonary hypertension and respiratory failure because of incarceration of the tumor to the mitral valve. Emergency surgery was performed, but the patient could not be weaned from cardiopulmonary bypass because of right ventricular failure. A Biomedicus centrifugal pump was used as a right ventricular assist pump. The result was a successful termination of cardiopulmonary bypass. With the support of an intra-aortic balloon pump, the right ventricular assist pump was removed 38 hours after the operation, and the intra-aortic balloon pump was terminated 2 days later. The centrifugal pump is very useful at the majority of centers where the pneumatically activated bi-valved ventricular assist device is unavailable. The Biomedicus centrifugal pump can be easily applied for treatment of perioperative right ventricular failure and is very useful for short-term use without systemic anticoagulants.     

A case of right ventricular failure after CABG successfully supported by right heart bypass with a centrifugal pump

A 67-year-old woman underwent CABG because of severe triple vessel disease. She could not wean from CPB in spite of full inotropic drugs and IABP support due to right ventricular failure probably caused by the perioperative right ventricular infarction. Right heart bypass (RHB) with a centrifugal pump was used. Finally she could wean from CPB and took an uneventful postoperative course except mediastinitis. During 5 days of RHB operation ACT was maintained between 180s and 200s by systemic heparinization. RHB with a centrifugal pump is a reliable method to assist a failing right ventricle.     

Anticoagulation therapy and circulatory management with left ventricular catheter under left ventricular bypass using centrifugal pump--an experience in a case with mitral valve replacement

A 53-year-old woman who had severe mitral regurgitation associated with moderate tricuspid regurgitation and mild aortic regurgitation underwent mitral valve replacement with a 27 mm Bj?rk-Shiley mechanical valve, left atrial plication and tricuspid annuloplasty. She fell into low output syndrome on the first postoperative day because of persistent intractable ventricular arrhythmia and eventually required open cardiac massage. The left ventricular (LV) bypass using a centrifugal pump was initiated with cannulation to ascending aorta and left atrium. Echocardiography showed LV wall motion extremely poor with the prosthetic valve being in closed posture. For prevention from thrombus formation on the prosthetic valve and in the LV, a catheter was inserted into LV through RV to give heparin and monitor the LV pressure. As the result, activated clotting time of LV was higher (range from 280-388 sec) than that of systemic blood (range from 182-258 sec). Also, the change of LV pressure was monitored through this LV catheter. Under this monitor, IABP was smoothly applied in the presence of aortic regurgitation, and she was weaned from LV-bypass successfully after 157 hrs support. She was discharge on the 77th postoperative day without thromboembolic complication.     

Experimental acute right ventricular failure and right ventricular assist in the dog

We describe a technique for the production of acute progressive right ventricular failure in experimental animals that mimics the hemodynamic characteristics of right ventricular failure found in some patients being weaned from extracorporeal circulation after surgical repair of left ventricular abnormalities. The technique combines three alterations of right ventricular state: excision of the tricuspid valve, ventriculotomy, and ligation of the right coronary artery. Seven control dogs died within 3 hours after this intervention. Death was due to low cardiac output as a result of low left atrial and pulmonary arterial pressures. Right atrial pressure was high. Use of a right ventricular assist device in an additional seven dogs to pump blood from the right atrium to the pulmonary artery confirmed good preservation of left ventricular function by reestablishing adequate left ventricular filling pressure. All seven dogs survived for more than 3 hours. The validity of the technique in restricting failure principally to the right ventricle was thus demonstrated.     

Clinical experience of a percutaneous ventricular support for profound heart failure following acute myocardial infarction--a case report]

Percutaneous biventricular support with centrifugal pump was applied to a 59-year-old man with profound heart failure following acute myocardial infarction. Direct coronary angioplasty was performed under percutaneous cardiopulmonary support (PCPS). After angioplasty, he could not be weaned from PCPS under IABP. We used percutaneous left ventricular support (PLVS) with transseptal left atrial cannulation. PLVS could not maintain effective assist flow and he developed a cardiogenic shock again. PCPS was added to PLVS, and percutaneous biventricular support was started. Assist flow ranged 1.7-3.0 L/min in PLVS, and 1.7-2.0 L/min in PCPS, and total assist flow was 3.4 L/min. Pulsatile pressure was obtained by adding IABP. The patient was successfully weaned from PCPS in 26 hours and PLVS in 118 hours. Patient is alive and well one year after PLVS. Combination of PLVS and PCPS is an effective ventricular support system, being less invasive than conventional method with thoracotomy, and may be useful for profound heart failure.     

A case report of biventricular assistance by means of ventricular assist device and IABP in postoperative biventricular failure

Three patients with biventricular failure were managed postoperatively with the aid of a right ventricular assist device (RVAD) and intraaortic balloon pumping (IABP) with favorable results. Among these three cases, two had multiple rheumatic valvular disease with cardiac cachexia and underwent combined valve replacement. Another who was suffered from heart failure with a large ventricular septal defect and tricuspid regurgitation had a VSD closure and tricuspid valve replacement. In all patients, the weaning from pump oxygenator was difficult even with large doses of catecholamine. Therefore, the pump oxygenator was switched to RVAD for right ventricular assistance and IABP for left ventricular assistance because these patients had had right ventricular failure dominant biventricular failure preoperatively. Though case 2 was lost 64 days after the surgery by retroperitoneal bleeding due to inadequate anticoagulant treatment, the other two cases recovered successfully from postoperative biventricular failure and were discharged from the hospital. The indications of this method and the criteria for RVAD weaning were discussed.     

Mechanical support for isolated right ventricular failure in patients after cardiotomy

BACKGROUND: Patients with acute right ventricular (RV) failure after cardiotomy have a poor prognosis. We evaluated the surgical and long-term outcomes of patients with isolated RV failure that required right ventricular assist device (RVAD) support. METHODS: Between 1991 and 2002, a total of 30 patients received RVAD support for isolated RV dysfunction. We evaluated survival, duration of mechanical support, post-RVAD hemodynamics, and RV function. RESULTS: Right ventricular failure developed in patients after coronary artery bypass surgery alone or combined with valve surgery (12 patients), valvular surgery (5), ascending aortic replacement (6), heart transplantation (3), and pulmonary endarterectomy (4). Mean age was 58 +/- 15 years, and 17 (57%) were women. Surgery was emergent in 5 (73%) patients. Centrifugal pumps were used in 21, extra corporeal membrane oxygenation in 8, and as Abiomed pump in 1 patient. Overall, 17 (57%) patients died while receiving assist device support, 3 of sepsis, 2 of stroke, and 12 of inability to wean from the device. We successfully weaned RVAD support in 13 (43%) patients, with a median duration of support of 5 days (range, 2-8 days). Ten survived to hospital discharge. After RVAD removal, mean pulmonary artery pressure was 25.1 +/- 6.5 mmHg, cardiac output was 4.8 +/- 2.0 liters, and central venous pressure was 16.5 +/- 3.7 mmHg. Echocardiogram after RVAD removal showed normal RV function in 2 patients and in 11 patients demonstrated improvement. CONCLUSION: After cardiotomy, patients with RV failure who require mechanical support continue to have increased mortality. For patients successfully weaned from the RVAD, residual RV dysfunction is compatible with survival. More liberal use of RV mechanical support may be indicated for patients with acute RV failure.     

A case of acute right ventricular infarction and life-saving right ventricular assistance following emergency coronary revascularization and resection of a left ventricular aneurysm--discussion of indication and proper assist flow volume]

Right ventricular assistance (RVA) using centrifugal pump in combination with IABP was used to treat a patient who was difficult to wean from a cardiopulmonary bypass following emergency coronary revascularization and resection of a ventricular aneurysm performed to treat acute right ventricular infarction due to a PTCA complication. After 131 hours of RVA at 3.2 to 4.8 l/min, it was possible to remove the pump. No heparin was administered during this time, changing the pump head twice, was used for 64 and 50 hour period, no thrombi were detected either time. After being weaned from RVA, the patient developed severe respiratory dysfunction, but on the 10th postoperative day (POD) IABP was weaned, and on the 13th POD the artificial respirator was withdrawn. The results of the postoperative cardiac catheterization were favorable, the patient was discharged on the 57th POD, and has returned to society at the present time. The indications for RVA include a central venous pressure > 20 mmHg and a cardiac index < 1.8 l/min/m2, and tissue perfusion pressure and general preoperative condition should severe as guides. The higher the assisted flow volume the more efficacious in relieving ventricular load, but, since there is a limit to how much the left ventricle and lungs can withstand, it should not exceed levels which ensure the maintainance of cardiac output and tissue perfusion pressure.     

Circulatory support with right ventricular assist device and intra-aortic balloon counterpulsation in patient with right ventricle failure after pulmonary embolectomy

Severe pulmonary embolism may lead to acute right ventricular failure despite immediate surgical embolectomy, which is regarded as the treatment of choice after recent CABG surgery. We report a case of a patient with massive pulmonary thromboembolism which resulted in acute right ventricular failure following early surgical embolectomy. Pulmonary embolism developed two days after an elective off-pump CABG surgery. We observed severe circulatory collapse which resulted in cardiac arrest and proved refractory to pharmacological treatment after immediate cardiopulmonary resuscitation. Intra-aortic balloon pumping was used in an attempt to improve hemodynamic performance during surgical skin preparation. After the completion of the embolectomy and failure to wean the patient from CPB, upon clinical signs of low cardiac output and akinetic right ventricle, the decision was made to support its function with a centrifugal pump. The substantial improvement of the right ventricular function observed in the next 24 h allowed weaning the patient from right ventricle support. In spite of hemodynamic recovery, the patient remained in a coma on discharge from the cardiac-surgical ICU after 18 days, and died 10 days later from systemic infection.     

Infarct exclusion for postinfarction left ventricular free wall rupture with severe congestive heart failure

A 70-year-old man was transferred to our hospital with severe congestive heart failure and ventricular arrhythmia due to acute myocardial infarction. He had experienced chest pain 3 weeks previously and was admitted to another hospital for dyspnea, where he required assist ventilation, 1 week prior to the transfer. An echocardiogram revealed a broad anteroseptal infarction and very poor left ventricular function with an ejection fraction (EF) of 22%. He remained in a severe congestive heart failure condition despite a full administration of catecholamines. Coronary angiogram findings revealed an occlusion of the proximal left anterior descending coronary artery and 1 week later severe hypotension was suddenly presented. An echocardiogram showed pericardial effusion with signs of cardiac tamponade. A pericardiocentesis was performed and hemodynamic improvement was obtained for a short time, after which the patient underwent urgent open heart surgery. During the operation, exclusion of the anteroseptal akinetic area using an oval patch was performed under a cardiopulmonary bypass and ventricular fibrillation. Severe cardiac failure remained postoperatively and the patient could not be weaned from cardiopulmonary bypass, therefore, we implanted a percutaneous cardiopulmonary support (PCPS) and started intraaortic balloon pumping (IABP). The patient was weaned from PCPS at 26 days after surgery and from IABP at 30 days. Following hospital release, he has continued to do well without heart failure for 39 months after the operation.     

High flow and high dose neosynephrine are effective to maintain perfusion pressure for the patient with preoperative angiotensin converting enzyme inhibitor during cardiopulmonary bypass

Angiotensin converting enzyme inhibitors (ACEIs) are widely used in the treatment of hypertension, myocardial infarction, and congestive heart failure. They have a known adverse effect of unresponsiveness to vasoconstrictors resulting in hypotension for the patients undergoing cardiac surgery. We report a case of a 43-year-old female patient with preoperative lisinopril (2.5 mg per day for a week prior to cardiac surgery), who was diagnosed with severe mitral and tricuspid valve regurgitation. She underwent both a mitral and tricuspid valve replacement operation using cardiopulmonary bypass (CPB). To address her ACEI-associated hypotension on cardiopulmonary bypass, bypass flows were as high as cardiac index of greater than 3 (3.1 +/- .2) L/min/m2 to provide sufficient perfusion indicated by cerebral oxymetry monitoring and adequate urine on pump. In addition, due to unresponsiveness to regular concentration of neosynephrine (neo), boluses of higher concentrations up to 320 microg/mL of neo were administered to maintain the perfusion pressure on pump. The patient was weaned from CPB uneventfully and was discharged home on postoperative day 7. Additional therapeutic treatment to ACEI-associated hypotension and unresponsiveness to neo for the patients undergoing cardiac surgery using CPB is reviewed as well in this paper.     

Advanced mitral-tricuspid disease with severe right ventricular dysfunction: the double-staged approach

Tricuspid valve surgery in the presence of severe right ventricular dysfunction and pulmonary hypertension secondary to mitral valve stenosis is associated with poor early outcomes. We report the case of a young patient, presenting with severe chronic mitral-tricuspid disease responsible for long-lasting pulmonary hypertension and altered right ventricular function, who initially underwent mitral valve replacement and 7 days later the correction of her tricuspid insufficiency. This 2-staged approach permitted progressive reduction of pulmonary pressure and partial right ventricular remodeling before closing the systolic release valve of the right ventricle represented by tricuspid regurgitation.     

Successful post-left ventricular aneurysmectomy left ventricular assist with a centrifugal pump]

A 71-year-old male with a left ventricular aneurysm underwent aneurysmectomy. The patient could be weaned from cardiopulmonary bypass with high-doses of dopamine and dobutamine, followed by immediate left ventricular failure and systemic hypotension. IABP could not be applied to the patient because of the kinked bilateral common iliac arteries. In this condition a centrifugal pump system was connected between left atrium and ascending aorta. With a pump flow of 2 L/min the patient returned to an intensive care unit. After 48 hours of left heart bypass with minimal anticoagulation with systemic heparinization the device could be removed. The patient recovered without any complications, such as thromboembolism, renal failure or mediastinitis. He discharged in fair condition 3 months after the operation.     

Cardiogenic shock in patient with posterior postinfarction septal rupture--successful treatment with extracorporeal membrane oxygenation (ECMO) as a ventricular assist device

Abstract   We present the case of a 62-year-old female patient admitted to our center for cardiogenic shock due to large inferior myocardial infarct. Echocardiography revealed dysfunction of left ventricle, dilation of right ventricle, mitral valve insufficiency, and a large posterior ventricular septal defect (VSD). Coronary angiography showed occlusion of the right coronary artery. An attempt of percutaneous coronary intervention (PCI) of right coronary and posterior descending artery was not successful due to old thrombi. Despite inotropes and intraaortic balloon pump (IABP) there was severe hemodynamic instability. Therefore, we commenced veno-arterial extracorporeal membrane oxygenation (ECMO) as a ventricular assist device (VAD). Immediately we obtained the stabilization of the patient and the improvement of the clinical conditions. The third day after implantation, the closure of the defect, mitral valve plasty, and bypass to posterior descending artery were performed. The patient was discharged from the hospital 59 days after the operation. Six months after the operation, the patient was in good condition.     

A comparative evaluation of pulmonary artery balloon counterpulsation and a centrifugal flow pump in an experimental model of right ventricular infarction

To compare the efficiency of pulmonary artery balloon counterpulsation and a centrifugal flow pump in reversing the hemodynamic consequences of acute right-sided heart failure, we employed both devices in 14 Yorkshire pigs in which right ventricular infarction was created via surgical ligation of branches of the right coronary artery. Pulmonary artery balloon counterpulsation improved some of the indicators of right heart failure, as manifested by significantly decreased right atrial pressure and increased mean systemic blood pressure. In contrast, the centrifugal flow pump consistently and significantly reversed all of the hemodynamic consequences of right ventricular infarction. In comparison to pulmonary artery balloon counterpulsation, the centrifugal flow pump resulted in lower right atrial pressures (p=0.020), lower mean pulmonary pressures (p less than 0.0001), increased left atrial pressures (p=0.026), increased cardiac output (p less than 0.0001), and increased mean systemic blood pressures (p less than 0.0001). Possible mechanisms to explain the superiority of the centrifugal flow pump include better hemodynamic unloading of the failing myocardium and independence from right ventricular output.     

Aortic pulmonary autograft implant: medium-term follow-up with a note on a new right ventricular pulmonary artery conduit

BACKGROUND: The Ross operation has been applied to various aortic valve pathologies, particularly when somatic growth is an issue. However, associated cardiac disease and technical problems may limit its use with regard to associated procedures and issues of right ventricular outflow reconstruction. MATERIALS AND METHODS: From December 1992 to March 1998, 24 patients underwent aortic pulmonary autograft implantation. There were 14 males and 10 females, 15+/-10 years of age (mean +/- SD) (range 1 to 50 years), weighing 42.8+/-20 kg (mean +/- SD) (range 8 to 78 kg). Aortic insufficiency was present in 15 (62.5%) patients, stenosis in 8 (33.3%) patients, and valvar stenosis associated with left ventricular outflow tract obstruction in 1 (4.1%) patient. Etiology was rheumatic in 17 patients and congenital in 7. The Ross procedure was accompanied by a partial-Konno left ventricular outflow enlargement in one patient, and mitral valve annuloplasty, mitral commissurotomy, and tricuspid valve replacement in three other patients, respectively. The right ventricular outflow was reconstructed with a valved pulmonary homograft in 14 patients and with a Shelhigh No-React porcine pulmonary conduit in 10 patients. Evaluation was done by New York Heart Association (NYHA) Class and by echocardiography at a follow-up of 22.8+/-24 months (mean +/- SD) (range 3 to 63 months). RESULTS: There were no operative mortalities and no postoperative arrhythmias. One (4.1%) patient required intra-aortic balloon pump (IABP) support for 3 days, one (4.1%) patient died 2 years later of probable arrhythmia, and one (4.1%) patient required mechanical aortic valve replacement 2 years later for severe autograft insufficiency. Left ventricular ejection fraction was unchanged (preoperative 62.4%+/-30%, postoperative 64.2%+/-30% [mean +/- SD], [p = NS]) and no significant gradient was documented by echocardiographic Doppler in the right and left ventricular outflow tracts. The aortic insufficiency scale decreased from a mean of 3.9+/-0.2 to a mean of 1+/-0 (p < 0.01). NYHA Class decreased to I in all patients, from III (10) and II (14). CONCLUSIONS: The pulmonary autograft in the aortic position is suitable for aortic valve replacement in pediatric and adult patients with good medium-term results and in patients with rheumatic etiology, and it provides a desirable solution in the presence of associated pathologies, such as left ventricular tract obstruction or associated multivalvular disease. The development of new means of right ventricular outflow reconstruction must parallel the progress achieved for the left side.     

Creation of an atrial septal defect for acute postperfusion right ventricular failure

Acute postperfusion right ventricular failure following mitral and aortic valve replacement in a patient with severe double-valve incompetence secondary to endocarditis is presented. The situation was reversed by creating an atrial septal defect that decompressed the right ventricle and increased left ventricular filling pressure.     

A case of unroofed coronary sinus with mitral and tricuspid valve regurgitation

A case of successfully treated unroofed coronary sinus associated with mitral and tricuspid valve regurgitation was reported. A 68 year-old male presented with congestive cardiac failure and pancytopenia due to hypersplenism. Investigation by cardiac catheterization and left ventricular angiography showed unroofed coronary sinus (left atrial to coronary sinus fenestration) combined with mitral and tricuspid valve regurgitation without persistent left superior vena cava. The atrial septum was intact. A large left-to-right shunt resulted in right heart failure. Direct suture closure of a coronary sinus defect and double valve replacements by using the SJM prosthetic valves were performed successfully.     

A successful biventricular assist for postoperative patient with severe heart failure and hepatorenal dysfunction after mitral and tricuspid valve surgery

We report a case of successful biventricular assist for severe heart failure after open heart surgery. A 62-year-old man suffering from advanced valvular disease accompanied with hepatorenal dysfunction underwent mitral valve replacement and tricuspid annuloplasty on September 22, 1988. Because of inability of weaning from cardiopulmonary bypass, left heart assisted circulation using a roller pump with heparin-coated tubing system was inserted. Following the left heart assist, an right ventricular assist device (RVAD) was subsequently applied to intractable right ventricular failure. He was successfully weaned from an RVAD after 24 hours, and from left heart assisted circulation after 46 hours. At present, he is doing well without significant complications. Earlier application of biventricular assist might be effective for biventricular failure with hepatorenal dysfunction.     

A surgical case of combined valvular disease complicated by absent right superior vena cava and persistent left superior vena cava.

A 74-year-old man with combined valvular disease with a recent cerebral infarction was admitted. While undergoing thorough examination for valvular disease, absent right superior vena cava (RSVC) and persistent left superior vena cava (PLSVC) were recognized. Chest X-ray film suggested a right arch protrusion, and CT and venogram confirmed the diagnosis. During surgery, replacement of the mitral and aortic valves and annuloplasty of the tricuspid valve were performed. A blood draining cannula was inserted in retrograde fashion from the coronary sinus into the PLSVC, without any difficulties in the tricuspid valve repair. Due to bradycardic atrial fibrillation, we believed that it would be difficult to insert an endocardial electrode postoperatively, hence myocardial electrode was placed in the right ventricular wall. Absent RSVC combined with PLSVC is very rare, and a patient who underwent combined valve surgery with this rare anatomical abnormality is herein presented.