The EXCOR paracorporeal VAD can be utilized to provide biventricular or univentricular mechanical circulatory support from mid- to long term [1–3]. Its main application is bridging to heart transplantation, but also bridge to recovery or to candidacy is possible. The most common configurations for EXCOR BVAD cannulation are depicted in Figs. 30.1 and 30.2:

Paracorporeal Biventricular Assist Devices: The EXCOR® VAD System

Objectives Cardiogenic shock from refractory right ventricular (RV) failure during left ventricular assist device placement is associated with high morbidity and mortality. The addition of extracorporeal membrane oxygenation to RV mechanical assistance may help RV recovery and lead to improved outcomes. Methods We retrospectively reviewed all implanted continuous-flow left ventricular assist devices from April 2009 to June 2013. RV mechanical support was utilized for RV failure defined as haemodynamic instability despite vasopressors, pulmonary vascular dilators and inotropic therapy. RV assist devices were utilized with and without in-line membrane oxygenation. Results During the study period, 267 continuous-flow left ventricular assist devices were implanted. RV mechanical support was utilized in 27 (10%) patients; 12 (46%) had the addition of in-line extracorporeal membrane oxygenation. The mean age of patients with a right ventricular assist device with membrane oxygenation was lower than that in patients with a right ventricular assist device alone (45.6 ± 15.9 vs 64.6 ± 6.5, P = 0.001). Support was weaned in 66% (10 of 15) of patients with right ventricular assist device (RVAD) alone vs 83% (10 of 12) of those with RVAD with membrane oxygenation (P = 0.42). The RVAD was removed after 10.4 ± 9.4 vs 5 ± 2.99 days for patients with a RVAD with membrane oxygenation (P = 0.1). Patients with RVAD with membrane oxygenation had a 30-day mortality rate of 8 vs 47% for those with RVAD alone (P = 0.04). The survival rate after discharge was 86, 63 and 54% at 3, 6 and 12 months for both groups combined. Conclusions Patients with a RVAD with membrane oxygenation support for acute RV failure after continuous-flow left ventricular assist device implantation had a lower 30-day mortality than those with a RVAD alone. Patients who survive to discharge have a reasonable 1-year survival. Combining membrane oxygenation with RVAD support appears to offer a short-term survival benefit in patients with RV failure after continuous-flow left ventricular assist device implantation.

Right ventricular assist device with membrane oxygenator support for right ventricular failure following implantable left ventricular assist device placement

Extracorporeal life support (ECLS) is generally considered to be the treatment of choice for bridging to heart transplantation (HTx) patients with cardiogenic shock; however, alternative mechanical circulatory support (MCS) devices have been proposed with satisfactory results and, among those, paracorporeal systems have demonstrated to be safe and effective. This technology has been used for decades as bridge to transplant, especially in patients with advanced right ventricular dysfunction or evidence of multiorgan failure (MOF), which could be difficult to manage with an isolated left ventricular support. Paracorporeal systems are defined by having the pump located outside of the body, with inflow and outflow cannulas that traverse the skin connecting the pump with the heart and great vessels. They can be utilised in a uni- or bi-ventricular configuration and can provide pulsatile or continuous flow, depending on the device technology (pneumatic vs. centrifugal). In particular, pneumatic devices allow for patient mobilization and hospital discharge, improving rehabilitation and organ recovery while bridging to transplant. In our institution at the University Hospital of Udine, 34 pneumatic paracorporeal ventricular assist devices (VADs) have been implanted since 1998: in most cases (32 pts), as biventricular support for patients in INTERMACS class I–II. After a median support time of 34 (range, 0–385) days, with 19 patients (56%) supported for more than 1 month, 23 patients (68%) underwent HTx and 3 (9%) were successfully weaned to hospital discharge, resulting in an overall combined 76% survival to HTx or weaning. After transplant, the survival rate was similar to the one of the patients not bridged with MCS. In conclusion, pneumatic VADs can effectively assist patients with severe biventricular failure, especially those with contraindications to ECLS or expected long waiting times for HTx. Moreover, they can potentially result in hospital discharge, optimal organ and patient recovery and donor-recipient matching, resulting in a satisfactory transplant outcome.

/pdf/short-term-mechanical-circulatory-support-as-bridge-to-heart-4j6sk7i5wf.pdf

Short-term mechanical circulatory support as bridge to heart transplantation: paracorporeal ventricular assist device as alternative to extracorporeal life support.

Introduction: In our centre there has been an increased use of BiVAD as bridge to heart transplantation (HTx) in patients with advanced biventricular heart failure. The survival rates after BiVAD implantation, earlier described in the literature, have mostly been dismal. It can also be difficult to predict the need for BiVAD instead of LVAD in the individual patient. The aim of our study was to describe the characteristics of our BIVAD patients and compare them with contemporary LVAD patients in respect to results and preoperative characteristics.

Patients and methods: During the period 2010-2012, 11 patients were implanted with the Excor BiVAD-system (Berlin Heart Excor) at the University Hospital (mean age 39 years, 73% male). All patients were in severe biventricular heart failure (mean CI 1,5 l/min x sqm, RAP 14 mmHg, PCWP 27 mmHg) and either on waiting list for transplantation or considered suitable for heart transplantation later on. BiVAD patients were compared to the contemporary 12 LVAD patients. Two different RV risk failure scores have also been calculated for each patient and will be discussed.

Results: 10/11 patients (91%) survived to HTx. The mean time of stay in the ICU after BiVAD implantation was 10 days and the mean time on assist 148 days. 9/11 patients were in INTERMACS class 1 or 2, 2/11 were in INTERMACS class 3. None of them had ischemic heart disease as the cause of heart failure. In comparison, LVAD patients (Heart Mate II, Thoratec) were older (mean age 56 years), had more ischemic heart disease (50%) and were all male. The survival rate was similar (10/12 patients, 83%) and so was the mean time of stay in the ICU (15 days). The LVAD patients had significantly better RV longitudinal function (measured by tissue Doppler), higher right ventricular stroke work index (RVSWI), higher cardiac index (1,9 l/min x sqm) and lower risk score for RV failure. Three patients had significant RV failure after LVAD implantation and two of those had to be bridged with RVAD.

Conclusion: Biventricular assist device is a good treatment option in selected patients with advanced biventricular heart failure. Although our population is small the results in this very sick group of patients are much more encouraging than earlier described. Our results also suggest that the use of BiVAD has been reasonable in relation to the characteristics of our patients.

/pdf/the-bivad-experience-at-the-university-hospital-results-from-d62uj4p8of.pdf

The BiVAD experience at the university hospital, results from the years 2010 to 2012 and comparison with contemporary LVAD patients

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The BiVAD experience at the university hospital, results from the years 2010 to 2012 and comparison with contemporary LVAD patients