A percutaneous modification of RVAD placement shows promise

Key clinical point: Use of a percutaneous modification of right ventricular assist device (RVAD) implantation appears to provide extended support duration and reduces the resternotomy risks, compared with conventional RVAD implantation.

Major finding: The survival rates to discharge or heart transplantation, and to 1 year, were 62% and 52%, respectively.

Data source: A retrospective review of 21 patients with RVF implanted with RVADs via the modified percutaneous placement technique.

Disclosures: The authors reported having no financial disclosures.

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An innovative technique for placing RVADs in LVAD patients

What makes this series unique is the fact that Dr. Saeed and his colleagues placed the RVAD inflow and outflow cannulae percutaneously to avoid the need for resternotomy for removal, according to the invited editorial commentary by Dr. Robert L. Kormos [doi:10.1016/j/jtcvs.2014.11.031].

“Although this is an expanded observational study, it should make us consider further trials to define the real benefits of this approach,” he stated. “The lingering question for all of us, however, is: How does the clinical community define the need for these systems? The balance, of course, will be between utilizing a lower clinical threshold for implantation of LVADs, thus reducing the inherent RV dysfunction, versus ease of insertion and management of percutaneous RVADs, which could lead to earlier RV support decisions, obviating the syndrome of multiorgan failure that accompanies RV failure, and promoting the potential for RV recovery.”

Dr. Kormos is is a professor of surgery at the Presbyterian University Hospital, University of Pittsburgh.




The use of a modified percutaneous placement technique for right ventricular assist device (RVAD) implantation showed the potential to lessen complications and improve outcomes, according to the results of a retrospective review of 21 patients with right ventricular failure (RVF) implanted with RVADs using this technique.

“This study shows the feasibility and safety of the proposed RVAD implantation technique for various forms of perioperative RVF. A satisfactory outcome can be achieved with a minimal rate of complications,” according to Dr. Diyar Saeed and colleagues at the Clinic for Cardiovascular Surgery, Heinrich-Heine University of Dusseldorf (Germany). Their report appears in the March issue of The Journal of Thoracic and Cardiovascular Surgery [doi:10.1016/j/jtcvs.2014.10.104].

Although this technique has been previously described anecdotally in a few case reports, this study is the largest series reported to date, according to the authors.

A total of 63 left ventricular assist devices (LVADs) were placed during the study period (January 2010 to February 2014); 17 (27%) of these patients subsequently received RVADs. An additional four patients were included who received RVADs after developing postcardiotomy RVF. The mean patient age of the RVAD patients 58 years, and 71% were men, The primary diagnosis was ischemic cardiomyopathy in 57% of the patients, dilative cardiomyopathy in 24%, and acute myocardial infarction in 19% .

The initial operation for RVAD implantation required a median sternotomy and was performed via cardiopulmonary bypass in 14 patients, LVAD support in 3 patients, ECMO support in 3 patients, and off-pump in 1 patient. A dacron graft was attached to the pulmonary artery and passed through a subxiphoid exit, where the RVAD outflow cannula was inserted. The inflow cannula was percutaneously cannulated in the femoral vein, and the sternum was primarily closed.

The median duration of RVAD support was 9 days (range 2-88 days). Explantation of the RVAD was performed by pulling and ligating the outflow graft followed by closure of the insertion site. The RVAD inflow cannula was removed and direct pressure applied.

The overall outcomes were that 52% of patients were successfully weaned from the RVAD; 38% of patients died; and 10% of patients received cardiac transplants, giving a survival rate to discharge or heart transplantation of 62%. The overall 1-year survival rate was 52%, but this comprised an improved survival rate of the 4 postcardiotomy patients (75%) compared with the 17 LVAD patients who received an RVAD (47%). Because of the small population size, these latter differences were not significant.

The main drawback of the technique is the limited mobility of the patients owing to the presence of the inflow cannula in the groin, according to the authors, with the majority of the patients remaining bed or chair bound.

“Early extubation, extended support duration, and reduction of resternotomy risks may be the main advantage of this technique. The RVAD removal can be reproducibly performed under minimal anesthesia and without the need for resternotomy. [However], the survival rate remains limited in patients requiring RVAD support after LVAD implantation,” the researchers concluded.

The authors reported having no financial disclosures.

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