Background Acute right ventricular failure (ARVF) refractory to optimal medical management may require rescue therapy with mechanical circulatory support (MCS). The RV exhibits a greater capacity for rapid recovery than the left ventricle, making devices designed specifically for temporary RV MCS attractive. We report our experience with the Impella Right Direct (RD) and Right Peripheral (RP) temporary ventricular assist devices (Abiomed, Danvers, MA) in patients with ARVF. Methods We conducted a retrospective cohort study examining the clinical outcomes of consecutive patients supported with the Impella RD or RP at 2 institutions during a 6-year period. Results During the study period, 18 patients (67% men; mean age 57 ± 10 years) received MCS, 15 with the Impella RD and 3 with the Impella RP. Before RV MCS, all patients required intravenous inotropes, 7 (39%) required inhaled nitric oxide, 7 (39%) required intra-aortic balloon counterpulsation, and 2 (11%) had experienced a cardiac arrest. Device implantation resulted in an improvement in cardiac index (2.1 ± 0.1 liters/min/m 2 pre-implant vs 2.6 ± 0.2 liters/min/m 2 post-implant, p = 0.04) and reduced central venous pressure (22 ± 5 vs 15 ± 4 mm Hg, p Conclusions Most patients with ARVF rapidly recover sufficient RV function to facilitate device explantation, highlighting an expanding role for minimally invasive temporary RV assist devices optimized for the treatment of recoverable ARVF.

Short-term mechanical circulatory support for recovery from acute right ventricular failure: clinical outcomes.

Acute right ventricular myocardial infarction (RVMI) is observed in 30-50% of patients presenting with inferior wall myocardial infarction (MI) and, occasionally, with anterior wall MI. The clinical consequences vary from no hemodynamic compromise to severe hypotension and cardiogenic shock depending on the extent of RV ischemia. Areas covered: The pathophysiological mechanisms, diagnostic steps, and novel therapeutic approaches of acute RVMI are described. Expert commentary: Diagnosis of acute RVMI is based on physical examination, cardiac biomarkers, electrocardiography, and coronary angiography, whereas noninvasive imaging modalities (echocardiography, cardiac magnetic resonance imaging) play a complementary role. Early revascularization, percutaneous or pharmacological, represents key step in the management of RMVI. Maintenance of reasonable heart rate and atrioventricular synchrony is essential to sustain adequate cardiac output in these patients. When conventional treatment is not successful, mechanical circulatory support, including right ventricle assist devices, percutaneous cardiopulmonary support, and intra-aortic balloon pump, might be considered. The prognosis associated with RVMI is worse in the short term, compared to non-RVMI, but those patients who survive hospitalization have a relatively good long-term prognosis.

Acute right ventricular myocardial infarction

Right ventricular failure (RVF) may still occur despite the benefits of minimally invasive left ventricular assist device (MI-LVAD) implantation. Our center strategy aims to avoid aggressive postoperative inotrope use by using mechanical support to facilitate right ventricle recovery and adaptation. We herein report first outcomes of patients with minimally invasive temporary right ventricular assist device (MI-t-RVAD) support for RVF during MI-LVAD implantation. Right ventricular failure was defined as requiring more than moderate inotopic support after weaning from cardiopulmonary bypass according to Interagency Registry for Mechanically Assisted Circulatory Support adverse event definitions. All patients requiring MI-t-RVAD support for RVF during MI-LVAD implantation between January, 2012 and April, 2016 were retrospectively reviewed. Clinical endpoints were death or unsuccessful RVAD weaning. Overall 10 patients (90% male, mean age 49.6 ± 14.8 years) underwent MI-t-RVAD implantation. Duration of MI-t-RVAD support was 16.2 ± 11.6 days. Right ventricular assist device weaning and subsequent uneventful awake device explantation was successful in all cases. The 30 day survival was 80%. Our results confirm safety and feasibility of MI-t-RVAD support for acute RVF in the setting of MI-LVAD implantation. The potential benefits of this strategy are more stable hemodynamics in the first postoperative days that usually are crucial for LVAD patients and reduced inotrope requirement.

Outcomes of Minimally Invasive Temporary Right Ventricular Assist Device Support for Acute Right Ventricular Failure During Minimally Invasive Left Ventricular Assist Device Implantation.

Temporary mechanical circulatory support (MCS) is a common supportive therapy in cardiogenic shock and high-risk coronary intervention. The proliferation of new percutaneous MCS devices allows support to be instituted rapidly without surgical cutdown. The recent literature exploring the indications, benefits, and risks of each is reviewed. Areas discussed: Current applications of percutaneous MCS devices, including intra-aortic balloon pumps (IAPB), Impella, TandemHeart, and VA ECMO are discussed. Studies investigating each were identified through a combination of online database queries and direct extraction of single studies cited in previously-identified papers. Information on unpublished trials and registries was found on ClinicalTrials.gov. Expert commentary: Direct VADs provide a higher level of hemodynamic support compared to IABP and their early use will continue to expand. The development of percutaneous RV support systems may allow more patients to receive such therapy faster. VA ECMO is being used increasingly in CPR and in outreach programs.

Novel percutaneous mechanical circulatory support devices and their expanding applications.

Purpose of reviewTo provide a comprehensive update on the current state of short-term, continuous-flow ventricular assist devices (CF-VADs) in the treatment of refractory cardiogenic shock in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 1 patients.Recent findingsThe

Short-term continuous-flow ventricular assist devices.

We report the first implantation in the United States of a novel percutaneous right ventricular (RV) support device as a bridge to recovery in a patient with RV infarction with cardiogenic shock refractory to standard care.

A 64-year-old man, with prior inferior wall myocardial infarction treated with percutaneous coronary intervention, presented with late drug-eluting stent thrombosis inferoposterior ST-segment–myocardial infarction complicated by cardiac arrest requiring defibrillation of ventricular tachycardia (Figure 1; Movie I and II in the online-only Data Supplement). Despite revascularization, fluid administration to a central venous pressure of 20 mm Hg, dobutamine and vasopressin infusions, and intra-aortic balloon pump counterpulsation, he remained in RV shock (cardiac index of 1.8 L/min per m2). With use of antiplatelet drugs, surgical cannulation for extracorporeal support was deemed an excessive risk.



Figure 1. 
Acute inferoapical ST-elevation–myocardial infarction (STEMI) treated …

First Experience With Implantation of a Percutaneous Right Ventricular Impella Right Side Percutaneous Support Device as a Bridge to Recovery in Acute Right Ventricular Infarction Complicated by Cardiogenic Shock in the United States

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First Experience With Implantation of a Percutaneous Right Ventricular Impella Right Side Percutaneous Support Device as a Bridge to Recovery in Acute Right Ventricular Infarction Complicated by Cardiogenic Shock in the United States