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Yuriditsky E, Chonde M, Friedman O, Horowitz JM. Medical and Mechanical Circulatory Support of the Failing Right Ventricle. Curr Cardiol Rep 2024; 26:23-34. [PMID: 38108956 DOI: 10.1007/s11886-023-02012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 12/19/2023]
Abstract
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. 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.
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Affiliation(s)
- Eugene Yuriditsky
- Division of Cardiology, Department of Medicine, NYU Langone Health, 530 First Ave. Skirball 9R, New York, NY, 10016, USA.
| | - Meshe Chonde
- Department of Cardiology, Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Oren Friedman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - James M Horowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, 530 First Ave. Skirball 9R, New York, NY, 10016, USA
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Kugo Y, Taira M, Watanabe T, Tominaga Y, Hasegawa M, Ueno T, Miyagawa S. Univentricular Conversion for Acquired Severe Right Ventricular Failure. Ann Thorac Surg 2023; 115:e75-e77. [PMID: 35367436 DOI: 10.1016/j.athoracsur.2022.03.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/07/2022] [Accepted: 03/12/2022] [Indexed: 11/18/2022]
Abstract
In a 14-year-old boy, prolonged right ventricular (RV) dysfunction due to postmyocarditis cardiomyopathy developed, whereas left ventricular function recovered with conservative treatment. On catheterization, the RV end-diastolic volume index was 184 mL/m2, and mean pulmonary artery pressure was 16 mm Hg. Despite one-and-a-half ventricle repair, RV dilation continued to worsen; therefore, 3 years after the operation, RV exclusion and extracardiac total cavopulmonary connection were performed. Postoperatively, left ventricular function was maintained, and no further RV dilation was observed. Univentricular conversion may be an effective procedure for the treatment of acquired severe isolated right-sided heart failure.
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Affiliation(s)
- Yosuke Kugo
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Masaki Taira
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takuji Watanabe
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuji Tominaga
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Moyu Hasegawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takayoshi Ueno
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Monteagudo-Vela M, Tindale A, Monguió-Santín E, Reyes-Copa G, Panoulas V. Right ventricular failure: Current strategies and future development. Front Cardiovasc Med 2023; 10:998382. [PMID: 37187786 PMCID: PMC10175590 DOI: 10.3389/fcvm.2023.998382] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 04/03/2023] [Indexed: 05/17/2023] Open
Abstract
Right heart failure can be defined as a clinical syndrome consisting of signs and symptoms of heart failure resulting from right ventricular dysfunction. Function is normally altered due to three mechanisms: (1) pressure overload (2) volume overload, or (3) a decrease in contractility due to ischaemia, cardiomyopathy or arrythmias. Diagnosis is based upon a combination of clinical assessment plus echocardiographic, laboratory and haemodynamic parameters, and clinical risk assessment. Treatment includes medical management, mechanical assist devices and transplantation if recovery is not observed. Distinct attention to special circumstances such as left ventricular assist device implantation should be sought. The future is moving towards new therapies, both pharmacological and device centered. Immediate diagnosis and management of RV failure, including mechanical circulatory support where needed, alongside a protocolized approach to weaning is important in successfully managing right ventricular failure.
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Affiliation(s)
- María Monteagudo-Vela
- Cardiothoracic Surgery Department, Hospital Universitario de la Princesa, Madrid, Spain
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- Correspondence: María Monteagudo-Vela
| | - Alexander Tindale
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Emilio Monguió-Santín
- Cardiothoracic Surgery Department, Hospital Universitario de la Princesa, Madrid, Spain
| | - Guillermo Reyes-Copa
- Cardiothoracic Surgery Department, Hospital Universitario de la Princesa, Madrid, Spain
| | - Vasileios Panoulas
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Comprehensive Monitoring in Patients With Dual Lumen Right Atrium to Pulmonary Artery Right Ventricular Assist Device. ASAIO J 2022; 68:1461-1469. [PMID: 35239539 PMCID: PMC9579997 DOI: 10.1097/mat.0000000000001684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Right ventricular assist devices (RVADs) can be used in patients with acute right heart failure. A novel device that has recently been deployed is the right atrium to pulmonary artery (RA-PA) dual lumen single cannula (DLSC). One of the limitations is that it occupies a large proportion of the right ventricular outflow tract and PA; therefore, standard continuous hemodynamic monitoring with a pulmonary artery catheter is commonly not used. Serial echocardiography is pivotal for device deployment, monitoring device position, assessing RV readiness for decannulation, and surveilling for short-term complications. We performed a retrospective case series of 24 patients with RA-PA DLSC RVAD assessing echocardiographic RV progression and vasoactive infusion requirements. The overall survival was 66.6%. The average vasoactive infusion score at the time of cannulation was 24.9 ± 43.9, at decannulation in survivors 4.6 ± 4.9 vs . 25.4 ± 21.5 in nonsurvivors, and 2.7 ± 4.9 at 48 hours post decannulation. On echocardiography, the average visual estimate of RV systolic function encoded (0 = none and 5 = severe) in survivors was 3.9 ± 1.2, 2.8 ± 1.6, 2.5 ± 1.7, and 2.8 ± 1.9, respectively, and in nonsurvivors 3.8 ± 1.6 and 3.4 ± 1.8, respectively. This demonstrated an RV systolic function improvement over time in survivors as opposed to nonsurvivors. This was also demonstrated in RV size visual estimate, respectively. Quantitatively, at the predefined four timepoints, the RV:LV, tricuspid annular plane systolic excursion, and fractional area change all improve over time and there is statistically significant difference in survivors versus nonsurvivors. In this study, we describe a cohort of patients treated with RA-PA DLSC RVAD. We illustrate the critical nature of echocardiographic measures to rate the progression of RV function, improvement in vasoactive infusion requirements, and ventilator parameters with the RA-PA DLSC.
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DeFilippis EM, Topkara VK, Kirtane AJ, Takeda K, Naka Y, Garan AR. Mechanical Circulatory Support for Right Ventricular Failure. Card Fail Rev 2022; 8:e14. [PMID: 35516793 PMCID: PMC9062706 DOI: 10.15420/cfr.2021.11] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/19/2021] [Indexed: 11/29/2022] Open
Abstract
Right ventricular (RV) failure is associated with significant morbidity and mortality, with in-hospital mortality rates estimated as high as 70–75%. RV failure may occur following cardiac surgery in conjunction with left ventricular failure, or may be isolated in certain circumstances, such as inferior MI with RV infarction, pulmonary embolism or following left ventricular assist device placement. Medical management includes volume optimisation and inotropic and vasopressor support, and a subset of patients may benefit from mechanical circulatory support for persistent RV failure. Increasingly, percutaneous and surgical mechanical support devices are being used for RV failure. Devices for isolated RV support include percutaneous options, such as micro-axial flow pumps and extracorporeal centrifugal flow RV assist devices, surgically implanted RV assist devices and veno-arterial extracorporeal membrane oxygenation. In this review, the authors discuss the indications, candidate selection, strategies and outcomes of mechanical circulatory support for RV failure.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Ajay J Kirtane
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, US
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Natanov R, Ricklefs M, Madrahimov N, Fleissner F, Haverich A, Kühn C. Minimal invasive temporary percutaneous right ventricular circulatory support after left ventricular assist device implantation. Interact Cardiovasc Thorac Surg 2021; 33:795-800. [PMID: 34270709 DOI: 10.1093/icvts/ivab167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Cardiogenic shock is a life-threatening situation with high mortality rates. Mechanical unloading of the left ventricle may be achieved via left ventricular assist device (LVAD) implantation. Postoperative right ventricular (RV) failure, however, has very limited therapeutic options and is associated with increased postoperative mortality. In this paper, we describe a percutaneous right heart bypass for temporary postoperative RV support. METHODS We retrospectively examined all patients receiving percutaneous RV mechanical support after LVAD implantation. All patients receiving trans-jugular mechanical right heart bypass during or after LVAD implantation in our tertiary medical centre between November 2014 and December 2019 were examined retrospectively. The venous draining cannula was placed in the femoral vein; the pulmonary cannula was placed in the pulmonary artery using fluoroscopy. RESULTS In total, 14 patients received RV support using the trans-jugular technique. Mean age was 48.4 ± 14.9 years. Nine patients were treated with mechanical circulatory support before LVAD implantation. Biventricular support was done in 7 patients. All patients were treated with an HVAD. Mean postoperative intensive care unit stay was 46.3 ± 32.4 days. Mean right heart bypass support time was 10.6 ± 4.3 days. Twelve patients (86%) could be bridged to RV recovery, RV assist device implantation or heart transplantation. CONCLUSIONS Percutaneous RV mechanical support is feasible, safe and shows acceptable outcome. Early implantation of RV support may contribute to successful outcome after LVAD implantation.
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Affiliation(s)
- Ruslan Natanov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Marcel Ricklefs
- Department of Cardiology, KRH Klinikum Siloah, Hannover, Germany
| | - Nodir Madrahimov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | | | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Abstract
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.
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Affiliation(s)
- Akbarshakh Akhmerov
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Boulevard, Suite A3105, Los Angeles, CA 90048, USA
| | - Danny Ramzy
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Boulevard, Suite A3105, Los Angeles, CA 90048, USA.
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Ren X, Johns RA, Gao WD. EXPRESS: Right Heart in Pulmonary Hypertension: From Adaptation to Failure. Pulm Circ 2019; 9:2045894019845611. [PMID: 30942134 PMCID: PMC6681271 DOI: 10.1177/2045894019845611] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/27/2019] [Indexed: 01/24/2023] Open
Abstract
Right ventricular (RV) failure (RVF) has garnered significant attention in recent years because of its negative impact on clinical outcomes in patients with pulmonary hypertension (PH). PH triggers a series of events, including activation of several signaling pathways that regulate cell growth, metabolism, extracellular matrix remodeling, and energy production. These processes render the RV adaptive to PH. However, RVF develops when PH persists, accompanied by RV ischemia, alterations in substrate and mitochondrial energy metabolism, increased free oxygen radicals, increased cell loss, downregulation of adrenergic receptors, increased inflammation and fibrosis, and pathologic microRNAs. Diastolic dysfunction is also an integral part of RVF. Emerging non-invasive technologies such as molecular or metallic imaging, cardiac MRI, and ultrafast Doppler coronary flow mapping will be valuable tools to monitor RVF, especially the transition to RVF. Most PH therapies cannot treat RVF once it has occurred. A variety of therapies are available to treat acute and chronic RVF, but they are mainly supportive, and no effective therapy directly targets the failing RV. Therapies that target cell growth, cellular metabolism, oxidative stress, and myocyte regeneration are being tested preclinically. Future research should include establishing novel RVF models based on existing models, increasing use of human samples, creating human stem cell-based in vitro models, and characterizing alterations in cardiac excitation–contraction coupling during transition from adaptive RV to RVF. More successful strategies to manage RVF will likely be developed as we learn more about the transition from adaptive remodeling to maladaptive RVF in the future.
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Affiliation(s)
- Xianfeng Ren
- Department of Anesthesiology,
China-Japan
Friendship Hospital, Beijing, China
| | - Roger A. Johns
- Department of Anesthesiology and
Critical Care Medicine,
Johns
Hopkins University School of Medicine,
Baltimore, MD, USA
| | - Wei Dong Gao
- Department of Anesthesiology and
Critical Care Medicine,
Johns
Hopkins University School of Medicine,
Baltimore, MD, USA
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