Mechanical Circulatory Support for Right Ventricular Primary Graft Dysfunction After Heart Transplant: A Review

Abstract

Primary graft dysfunction (PGD) is the most common cause of early mortality following heart transplantation. Although PGD can affect both ventricles, isolated right ventricular dysfunction (RV-PGD) is observed in nearly half of PGD patients. RV-PGD requires specific medical management to support the preload, afterload, and function of the failing RV; however, the use of mechanical circulatory support of the RV (RV-MCS) might be required when optimal medical therapy is insufficient in preventing forward failure and retrograde venous congestion. While RV-MCS options provide the opportunity to prevent or to recover from circulatory shock states, MCS is associated with a significant risk of complications. As a result of recent developments in short-term mechanical support devices, less invasive, percutaneous options for RV-MCS are available. In this review, we discuss the available devices, their advantages and disadvantages, and reported outcomes in RV-PGD.

Keywords: heart transplant; mechanical circulatory support; primary graft dysfunction.

FIGURE 1

Proposed algorithm for the initiation of right ventricular mechanical support. CI, cardiac index; MAP, mean arterial pressure; NO, nitric oxide; PCWP, pulmonary capillary wedge pressure; PVR, pulmonary vascular resistance; RAP, right atrial pressure; RV, right ventricular; sPAP, systolic pulmonary artery pressure.

FIGURE 2

Mechanical circulatory support options for RV support. (A) RA‐PA RV bypass with extracorporeal pump (CentriMag, TandemHeart, ProtekDuo), (B) RA‐PA RV bypass with axial pump (Impella RP), (C) RA‐Ao right ventricular bypass with extracorporeal pump (V‐A ECMO). In the RA‐PA configuration, right ventricular preload (right atrial pressure) is reduced, while the mean pulmonary arterial pressure and pulmonary capillary wedge pressure increase. Consequently, perfusion of the pulmonary circulation is preserved. Left ventricular afterload remains unchanged and the left‐sided cardiac output increases. In the case of a RA‐Ao configuration, a decrease is seen in right atrial pressure, mean pulmonary artery pressure, pulmonary artery pressure and pulmonary capillary wedge pressure, but a significant increase occurs in left ventricular afterload. The left sided cardiac output decreases, but overall organ perfusion is maintained. Created with BioRender.com. Ao, aorta; PA, pulmonary artery; RA, right atrium; RV, right ventricle; RP, right peripheral; V‐A ECMO, veno‐arterial extracorporeal membrane oxygenation.