Discussion:
In our case, excision of the MV apparatus predisposed to the LV rupture
- a recognised complication following MV replacement, although its
incidence has reduced with sparing of the native valve. The prolonged
procedure and CPB time resulted in RV failure.
Acute RV failure is a well-recognized cause of morbidity and mortality
following cardiac surgery. It is seen more often after left ventricular
assist device implantation (20–30%), heart transplantation (2–3%)
and only in 0.04–0.1% of patients following cardiac
surgery.1
Patients with acute RV failure post-cardiotomy have a poor prognosis. In
a series of 30 patients undergoing RVAD implantation for isolated RV
failure following cardiac surgery over an 11-year period to 2012, 13
patients were successfully weaned from RVAD and of these, 10 survived to
discharge. The median duration of support was 5 days.2
There have been 2 reports of insertion of an implantable RVAD following
post-cardiotomy RV failure with successful weaning from the RVAD and
explantation at 15 and 79 days of support,
respectively.3,4 One patient developed a stroke and
both needed redo sternotomy and surgery, which in itself is also
associated with increased risk.
VA-ECMO was used initially as a bridge to recovery or decision in our
unstable patient. ECMO provides adequate cardiopulmonary support in some
instances but does not unload the ventricles to the degree possible with
a ventricular assist device.
To our knowledge, this is the first report of the successful use of a
percutaneous Protek Duo RVAD post-cardiotomy. The Protek Duo RVAD is a
good option for short-term RV support in isolation or with other LV
support devices for bi-ventricular support. However, it requires access
to a hybrid theatre and Cardiology support, as well as input from
cardiac surgeons and intensivists and was felt to be inappropriate as a
first-line treatment. Percutaneously placed with IJV access and with an
oxygenator added to the circuit, it provides both RV and respiratory
support, and allows patient mobility and rehabilitation while on
support.
This case illustrates that VA-ECMO can act as an effective short-term
bridge to recovery or further support with a percutaneous RVAD. The case
also shows that early and aggressive treatment of RV failure can have a
positive outcome and this strategy should be considered in selected
patients.