Combined Left Ventricular Assist Device and Temporary Right Ventricular Assist Device for End- Stage Heart Failure of Different Etiologies: A Case Series and Analysis of Perioperative Management Strategies

Technical Summary: Combined LVAD and Temporary RVAD for End-Stage Heart Failure

Problem Statement
Approximately one-third of patients with end-stage heart failure present with concomitant biventricular dysfunction. While Left Ventricular Assist Device (LVAD) implantation is a critical salvage therapy, isolated LVAD placement in patients with severe preoperative right ventricular (RV) dysfunction carries an extremely high risk of refractory postoperative right heart failure, significantly increasing perioperative mortality. The pathophysiology involves a sudden surge in venous return following left ventricular unloading, which can rapidly unmask and aggravate underlying RV dysfunction. Currently, clinical data regarding the combined use of the domestic, fully magnetically levitated Corheart 6 LVAD and an extracorporeal temporary Right Ventricular Assist Device (RVAD) for end-stage heart failure of different etiologies (specifically ischemic vs. dilated cardiomyopathy) remains limited. There is a need to evaluate the feasibility, safety, and perioperative management strategies for this combined approach in high-risk Chinese populations.

Methodology
This study is a retrospective case series analyzing two patients with end-stage heart failure and severe preoperative RV dysfunction at Nanjing First Hospital.

• Patient Cohort:
  • Case 1: A 66-year-old male with ischemic cardiomyopathy, multi-vessel coronary artery disease, and acute decompensated heart failure (INTERMACS profile 3). He had a Michigan Right Ventricular Failure Risk Score of 7 (high risk).
  • Case 2: A 45-year-old male with dilated cardiomyopathy, chronic renal insufficiency, and acute decompensated heart failure (INTERMACS profile 2). He had a Michigan Right Ventricular Failure Risk Score of 11 (very high risk).
• Intervention: Both patients underwent concomitant implantation of a Corheart 6 magnetically levitated LVAD and an extracorporeal magnetically levitated temporary RVAD (Extra-VAD) under general anesthesia with cardiopulmonary bypass (CPB).
  • Case 1 also underwent concomitant coronary artery bypass grafting (CABG).
  • Case 2 received preoperative optimization via continuous renal replacement therapy (CRRT) to manage volume overload.
• Perioperative Management:
  • Hemodynamics: Target cardiac index was ≥2.4 L/(min·m²). RVAD speed was adjusted based on Central Venous Pressure (CVP) to maintain a centered interventricular septum, with CVP kept <14 mmHg. LVAD flow was maintained 5–10% higher than RVAD flow.
  • Anticoagulation: Individualized regimens using Unfractionated Heparin (UFH) bridging to Warfarin, with intensity adjusted based on bleeding risk and etiology (e.g., lower ACT targets for the ischemic case to protect graft patency).
  • Weaning: Daily bedside echocardiography guided the stepwise reduction of RVAD rotational speed. Weaning occurred only after confirming circulatory stability and adequate RV contractility.

Key Results

• Surgical Outcomes: Both operations were completed successfully. CPB times were 171 min (Case 1) and 164 min (Case 2).
• Device Weaning: The temporary RVAD was successfully weaned and removed on postoperative day (POD) 7 for Case 1 and POD 4 for Case 2.
• Complications:
  • Case 1: Experienced transient gastrointestinal bleeding, managed with temporary anticoagulation suspension and transfusion, followed by successful resumption.
  • Case 2: Developed Staphylococcus aureus pulmonary infection and delirium, which were controlled with upgraded antibiotics and symptomatic psychiatric intervention.
  • No cases of pump thrombosis, severe intracranial hemorrhage, or pulmonary hemorrhage occurred.
• Recovery: Both patients were discharged on POD 40 and POD 50, respectively. At the 2-month follow-up, both exhibited stable hemodynamics, significantly improved cardiac function (increased LVEF and TAPSE), and no device-related complications. Echocardiography showed reduced cardiac chamber dimensions and normalized pulmonary pressures.

Significance and Claims
The paper posits that concomitant LVAD and temporary RVAD implantation is a safe and feasible option for selected patients with end-stage heart failure of different etiologies complicated by high-risk RV dysfunction. The study highlights several specific contributions:

1. Etiology-Specific Management: It demonstrates that perioperative strategies must be tailored to the underlying cause. Ischemic cardiomyopathy requires concomitant revascularization and conservative anticoagulation to protect grafts, whereas dilated cardiomyopathy with renal failure requires aggressive preoperative volume management (CRRT) and strict infection control.
2. Device Synergy: The combination of the small, hemocompatible Corheart 6 LVAD with the reversible, extracorporeal Extra-VAD provides a "bridging" strategy that allows for the recovery of RV function without the immediate need for permanent BiVAD implantation or heart transplantation.
3. Weaning Protocol: The study establishes a protocol for RVAD weaning based on daily echocardiographic assessment of the interventricular septum and CVP, rather than fixed timelines, noting that weaning duration varies by etiology (longer for ischemic due to reperfusion injury, shorter for dilated once volume is optimized).
4. Limitations: The authors explicitly state that due to the small sample size (n=2) and short follow-up (2 months), the findings are preliminary. They acknowledge that the generalizability is limited and that further validation in large, multicenter cohorts is required to confirm long-term prognosis and device durability.

In conclusion, the paper suggests that precise volume management, individualized anticoagulation, and etiology-based perioperative strategies are critical to improving prognosis in this high-risk population, offering a viable alternative to isolated LVAD implantation when severe RV dysfunction is present.