Imaging Modalities for Correct Positioning of Percutaneous Right Ventricular Assist Device After Left Ventricular Assist Device Implantation

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A 65-year-old male with nonischemic cardiomyopathy, recent ventricular tachycardia-induced cardiac arrest, supported by inotropic medications and intraaortic balloon pump, presented for biventricular assist device placement. Preoperative echocardiographic findings showed left ventricular (LV) ejection fraction of 15%, previous mitral valve annuloplasty, moderate-to-severe right ventricular (RV) dysfunction and moderate tricuspid regurgitation (TR). He underwent placement of HVAD (HeartWare International Inc, Framingham, MA), left ventricular assist device (LVAD), percutaneous right ventricular assist device (RVAD), tricuspid valve (TV) annuloplasty, and removal of intraaortic balloon pump. The HVAD was inserted first and the correct position of cannulas was confirmed with transesophageal echocardiography (TEE). The Impella RP (Right Peripheral, Abiomed, Danvers, MA) sheath, followed by microaxial pump were advanced via femoral venous access into the pulmonary artery (PA) under direct surgical visualization of the pig-tailed guidewire in the left PA. Post bypass TEE confirmed LVAD inflow and outflow cannulas in good position, RVAD inlet opening in the inferior vena cava (IVC) and the RVAD outlet opening 2.5 cm distal to the pulmonic valve (PV), and a well-seated tricuspid ring with mild TR and pulmonary regurgitation (PR). Impella RP was seated well in the RV without interfering with papillary muscles, chordae, pacer wires or PA catheter, or displacing the leaflets as it crossed the TV and PV (Figure 1; Supplemental Digital Content 1, Video 1,; Supplemental Digital Content 2, Video 2, At the end of the surgery, the patient was left with open chest, on low dose inotropic and vasopressor support, and inhaled epoprostenol. The HVAD flow was maintained 4.6 L/min and the Impella RP flow was 3.6 L/min. On postoperative day 1, the patient presented with systemic hypotension, increased pressor and inotropic support, reduced flows from both devices (HVAD flow 3.2 L/min; Impella 3.2 L/min) and elevated serum lactate. He was taken to the operating room with concern for cardiac tamponade; however, other causes of hemodynamic compromise such as RV failure, LV suck down effect or cannula malposition were considered as well. In addition to a moderate size pericardial effusion, TEE showed severely dilated RV, and underfilled LV with leftward-shifted interventricular septum. The Impella RP outlet was visualized in the proximity of the pulmonic root (Supplemental Digital Content 3, Video 3, Part A, The RV dilation was attributed to moderate PR, as a result of leaflet tenting by the Impella RP. The device was advanced by 2 cm, assuring parallel alignment with the main PA, which resulted in subsequent improvement in the LV filling, return of the interventricular septum position to midline, and noticeable decrease in PR (Supplemental Digital Content 3, Video 3, Part B, Subsequently, the RV systolic function recovered and the Impella RP was removed on postoperative day 6.
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