Temporary Right Ventricular Support Using the Existing Bypass Circuit During LVAD Implantation

Abstract

Background: Right-sided heart failure after left ventricular assist device (LVAD) implantation carries high morbidity. We sought to develop a technique for expedient short-term right ventricular (RV) support with the cardiopulmonary bypass (CPB) circuit already in use during the LVAD implantation procedure.

Methods: Patients at high risk for RV failure during LVAD implantation were supported by a modified CPB circuit. A standard CPB circuit was modified to include a series of 4 wye (Y) bridge connections, allowing the ability to exclude the venous reservoir and oxygenator and to flow venous blood or arterialized blood in the same CPB outflow line.

Results: From 2019 to 2022 at a single institution, 6 patients were identified as high risk for early RV failure. Preoperative mean clinical values included central venous pressure of 16.3 ± 3.2 mm Hg, pulmonary capillary wedge pressure of 26.7 ± 3.2 mm Hg, tricuspid annular plane systolic excursion of 1.2 ± 0.23 cm, RV stroke work index of 311.7 ± 32.5, and central venous pressure/pulmonary capillary wedge pressure of 0.61 ± 0.10. All 6 patients were successfully weaned from CPB to LVAD support without the need for RV support at the conclusion of the implantation procedure.

Conclusions: We describe a configuration that supports the right ventricle during the critical period after CPB when it is at high risk of failure while the patient is being resuscitated with transfusions and volume. This technique provides flexibility in the management of complex, critically ill patients with RV failure, increasing the possibility of intraoperative RV recovery and successful separation from CPB during LVAD implantation.

Figure 1

Modified cardiopulmonary bypass circuit with clamped configuration allowing deoxygenated blood to outflow line, bypassing reservoir and oxygenator. Blue clamps removed indicate deoxygenated pathway.

Figure 2

Modified cardiopulmonary bypass circuit. (A) Full circuit with 4 additional wye connections. (B) First wye at top of reservoir allows venous return to reservoir or direct to pump inflow. (C) Second wye connection allows pump inflow from reservoir or venous inflow line established above. (D) Third and fourth wye connections allow pump outflow through the oxygenator or directly to the patient.