Management of penetrating cardiac injury and tricuspid regurgitation with extracorporeal-membrane oxygenation (ECMO): a case report.

BACKGROUND: Gunshot wounds (GSW) to the heart are lethal, and most patients die before they arrive to the hospital. Survival decreases with number of cardiac chambers involved. We report a case of a 17-year-old male who survived a GSW injury involving two cardiac chambers with acute severe tricuspid regurgitation (TR) who subsequently developed cardiogenic shock requiring extracorporeal membrane oxygenation (ECMO) support. CASE PRESENTATION: A 17-year-old male sustained a single gunshot wound to the left chest, resulting in pericardial tamponade and right hemothorax. Emergency sternotomy revealed injury to the right ventricle and inferior cavoatrial junction with the adjacent pericardium contributing to a right hemothorax. The cardiac injuries were repaired primarily. Tricuspid regurgitation was confirmed immediately postoperatively. Five days after presentation, the patient developed cardiogenic shock secondary to TR requiring emergent stabilization with ECMO. He subsequently underwent successful tricuspid valve replacement. CONCLUSIONS: This is the first report to our knowledge of successful ECMO support of severe TR due to gunshot injury to the heart.

Pericardial Adipose Tissue Thrombospondin-1 Associates With Antiangiogenesis in Ischemic Heart Disease.

Accumulation of ectopic pericardial adipose tissue has been associated with cardiovascular complications which, in part, may relate to adipose-derived factors that regulate vascular responses and angiogenesis. We sought to characterize adipose tissue microvascular angiogenic capacity in subjects who underwent elective cardiac surgeries including aortic, valvular, and coronary artery bypass grafting. Pericardial adipose tissue was collected intraoperatively and examined for angiogenic capacity. Capillary sprouting was significantly blunted (twofold, p <0.001) in subjects with coronary artery disease (CAD) (age 60 ± 9 years, body mass index [BMI] 32 ± 4 kg/m2, low-density lipoprotein cholesterol [LDL-C] 95 ± 46 mg/100 ml, n = 29) compared with age-, BMI-, and LDL-C matched subjects without angiographic obstructive CAD (age 59 ± 10 y, BMI 35 ± 9 kg/m2, LDL-C 101 ± 40 mg/100 ml, n = 12). For potential mechanistic insight, we performed mRNA expression analyses using quantitative real-time polymerase chain reaction and observed no significant differences in pericardial fat gene expression of proangiogenic mediators vascular endothelial growth factor-A (VEGF-A), fibroblast growth factor-2 (FGF-2), and angiopoietin-1 (angpt1), or anti-angiogenic factors soluble fms-like tyrosine kinase-1 (sFlt-1) and endostatin. In contrast, mRNA expression of anti-angiogenic thrombospondin-1 (TSP-1) was significantly upregulated (twofold, p = 0.008) in CAD compared with non-CAD subjects, which was confirmed by protein western-immunoblot analysis. TSP-1 gene knockdown using short hairpin RNA lentiviral delivery significantly improved angiogenic deficiency in CAD (p <0.05). In conclusion, pericardial fat in subjects with CAD may be associated with an antiangiogenic profile linked to functional defects in vascularization capacity. Local paracrine actions of TSP-1 in adipose depots surrounding the heart may play a role in mechanisms of ischemic heart disease.

Sex-based outcomes in surgical repair of acute type A aortic dissection: A meta-analysis and meta-regression.

OBJECTIVE: Epidemiologic variation with respect to sex has been established in aortic dissection. However, current literature on sex-based outcomes in patients with aortic dissection is conflicting. In this study we aimed to compare perioperative outcomes according to sex in patients treated surgically for acute type A aortic dissection. METHODS: PubMed/MEDLINE, Embase, and Web of Science were searched for studies that reported sex-based differences in postoperative outcomes among patients with acute type A aortic dissection. The primary outcome was in-hospital/30-day mortality, and secondary outcomes included postoperative stroke, renal failure requiring dialysis, and reoperation for bleeding. Data were aggregated using the random effects model as pooled risk ratio (RR). Meta-regression was applied to identify sources of heterogeneity between studies. RESULTS: Nine of 1022 studies were included for final analysis comprising 3338 female and 5979 male participants. Compared with male sex, female sex was associated with similar in-hospital/30-day mortality (RR, 1.04; 95% CI, 0.85-1.28; P = .67), postoperative stroke risk (RR, 1.07; 95% CI, 0.91-1.25; P = .43), and postoperative risk of acute renal failure requiring dialysis (RR, 0.84; 95% CI, 0.59-1.19; P = .32). A decreased risk of reoperation for bleeding (RR, 0.84; 95% CI, 0.75-0.94; P < .01) was observed in female participants. Meta-regression analysis indicated that differences in preoperative shock were a source of heterogeneity in the sex difference in in-hospital/30-day mortality across studies. CONCLUSIONS: Among patients treated surgically for acute type A aortic dissection, female sex was not associated with increased risk of short-term mortality nor with major postoperative complications. Male sex was associated with a greater risk of postoperative bleeding.

Primary cardiac lymphoma.

OBJECTIVE: This study aimed to understand the population-level treatment modalities and to evaluate the survival benefits of surgical resection in primary cardiac lymphoma. METHODS: We queried the Surveillance, Epidemiology, and End Results Program database, which covers 35% of the US population. Patients with a histologic diagnosis of primary cardiac lymphoma from 1973 to 2015 were included. Multivariable accelerated failure time regression was performed to evaluate the associations between clinical factors and overall survival. RESULTS: A total of 184 patients were identified. The median age was 68 years, 80% were White, and 46% were women. Diffuse large B-cell lymphoma (80%) was the most common histology, and the majority (65%) was low-stage lymphoma (Ann Arbor stage I or II). Median survival was 2.2 years. Seventy-three percent of patients received chemotherapy. Only 10% of patients received local resection or debulking. Multivariable analysis demonstrated that local resection or debulking was not independently associated with overall survival (adjusted hazard ratio, 0.67; 95% confidence interval, 0.30-1.48; P = .32). Instead, chemotherapy (adjusted hazard ratio, 0.4; 95% confidence interval, 0.23-0.69; P < .001) was independently associated with improved survival, whereas increasing age (adjusted hazard ratio of 5-year increment, 1.13; 95% confidence interval, 1.04-1.22; P <.001) and advanced stage (adjusted hazard ratio, 2.18; 95% confidence interval, 1.33-3.56; P < .001) were independently associated with worse survival. CONCLUSIONS: Surgical resection was not independently associated with survival in patients with primary cardiac lymphoma. Chemotherapy was the predominant treatment option and associated with improved survival, whereas increasing age and advanced stage were independently associated with worse outcomes.

Primary Pericardial Mesothelioma: A Population-Based Propensity Score-Matched Analysis.

Primary pericardial mesothelioma is a rare malignancy of the mesothelial lining of the pericardium. This study aimed to evaluate the clinical characteristics and survival outcomes of these patients using a United States population-based cancer database. We queried the Surveillance, Epidemiology, and End Results program (1973-2015). Primary pericardial mesothelioma patients with complete follow-up data were included, and primary pleural mesothelioma patients were identified as controls. Propensity-score matching was used to balance individual characteristics. Kaplan-Meier analysis and log-rank tests were performed to compare overall survival. Forty-one primary pericardial mesothelioma and 15,970 primary pleural mesothelioma patients were identified. Before matching, when compared to the pleural mesothelioma counterparts, primary pericardial mesothelioma patients were younger (median 57 vs 73 years, P < 0.001), more likely to be female (46.3% vs 20.2%, P < 0.001), more likely to be nonwhite (24.4% vs 8.4%, P = 0.001), and less likely to have been diagnosed in the most recent study decade (2006-2015, 34.1% vs 43.5%, P = 0.002). The overall 1- and 2-year survival rates were 22.0% and 12.2%, with a median survival of 2 months (IQR: 1-6). After 1:2 nearest neighbor propensity-score matching, 38 pericardial mesothelioma and 76 matched pleural mesothelioma cases were identified. The 2 matched groups had comparable baseline characteristics, including age, sex, race, year of diagnosis, histological type, and cancer history. Compared to their pleural mesothelioma counterparts, primary pericardial mesothelioma patients were less likely to receive chemotherapy (23.7% vs 50.0%, P = 0.01) and had worse overall survival (median survival: 2 vs 10 months, log-rank P = 0.006). Primary pericardial mesothelioma has worse survival outcomes than pleural mesothelioma, with a median survival of only 2 months. These patients should seek care from experienced multidisciplinary teams at tertiary care centers that handle high volumes of mesothelioma patients.

Traumatic thoracic rib cage and chest wall hernias: A review and discussion of management principles.

Traumatic thoracic or chest wall hernias are relatively uncommon but highly challenging injuries that can be seen after a variety of injury mechanisms. Despite their description throughout history there remains scant literature on this topic that is primarily limited to case reports or series. Until recently, there also has been no effort to create a reliable grading system that can assess severity, predict outcomes, and guide the choice of surgical repair. The purpose of this article is to review the reported literature on this topic and to analyze the history, common injury mechanisms, likely presentations, and optimal management strategies to guide clinicians who are faced with these challenging cases. We also report a modified and updated version of our previously developed grading system for traumatic chest wall hernias that can be utilized to guide surgical management techniques and approaches.

Extracorporeal membrane oxygenation in the management of granulomatosis with polyangiitis.

Granulomatosis with polyangiitis (GPA, also known as Wegener's granulomatosis) is a type of systematic vasculitis that primarily involves the lung and kidney. Diffuse alveolar hemorrhage (DAH) and associated acute respiratory failure are uncommon but devastating complications of GPA. Experience in using extracorporeal membrane oxygenation (ECMO) to manage DAH caused by GPA is limited. We report two GPA patients with DAH that were successfully managed using ECMO support. Examining 13 cases identified in the literature and two of our own, we observed that most patients experienced rapid deterioration in respiratory function in conjunction with a precedent respiratory infection. All 15 patients received veno-venous ECMO support. The median duration of ECMO support was 11 days (interquartile range: 7.5-20.75 days). Bleeding was the most common complication, seen in four (26.7%) cases. All patients were successfully weaned off ECMO after a median length of hospital stay of 42 days (interquartile range: 30-78 days). We demonstrated that the use of ECMO is a reasonable and effective support option in the management of GPA patients with DAH. The risk of bleeding is high but maybe reduced using a lower anticoagulation goal.

Aortoventricular Dissociation and Refractory Fungal Endocarditis Caused by a Rare Pathogen Lichtheimia: A Surgical and Medical Management Strategy.

We report a rare case of prosthetic valve fungal endocarditis caused by Lichtheimia, a subspecies of the order Mucorales. The patient experienced complicated prosthetic valve endocarditis less than 2 months after uneventful coronary artery bypass grafting (CABG) and 2 aortic valve replacements. Ultimately surgical management required aortic root replacement and lifelong antimicrobial agents. We believe this is the first case of fungal endocarditis caused by Lichtheimia.

Acuity adaptable patient care unit system shortens length of stay and improves outcomes in adult cardiac surgery: University of Wisconsin experience.

OBJECTIVES: The Acuity Adaptable Patient Care (AAC) unit system allows all beds within a nursing unit to negate the need for transfer with changes in patient status. The unit is specialty specific to all levels of patient care. This system was implemented in March 2006 for cardiothoracic surgery at our institution. The purpose of this study was to evaluate the impact of the AAC system on the outcomes after adult cardiac surgery. METHODS: We retrospectively reviewed 2930 consecutive patients who underwent major adult cardiac procedures between January 2003 and December 2010. The cohorts were divided into the pre-AAC group (January 2003 to February 2006, n = 1029) and the AAC group (March 2006 to December 2010, n = 1901). Patient demographics and postoperative outcomes were assessed. RESULTS: The proportion of coronary artery bypass grafting was significantly lower (pre-AAC vs AAC: 43 vs 35%, P < 0.01), while those of aortic procedure (4 vs 11%, P < 0.01) and mechanical assist device insertion (3 vs 5%, P = 0.02) were higher in the AAC group. After the implementation of the AAC system, the incidence of all complications defined by the Society of Thoracic Surgeons (STS) database (49 vs 34%, P < 0.01), the median length of intensive care unit (ICU) stay (49 [interquartile range (IQR), 27-99] vs 26 [19-45] h, P < 0.01), that of hospital stay (6 [4-10] vs 5 [4-7] days, P < 0.01) and the readmission rate of ICU (5 vs 2% P < 0.01) were significantly decreased. Significant reductions in hospital mortality and the rate of hospital readmission <30 days were not observed. CONCLUSIONS: The implementation of the AAC system has improved the outcomes after major cardiac procedures. The incidence of postoperative complications and length of stay have all decreased significantly without increasing readmission rate. AAC creates a system of fluid care with specialty-trained nursing and other ancillary support that expedites discharge and improves overall patient outcomes.

Transapical mitral valved stent implantation: a survival series in swine.

OBJECTIVE: To assess short-term survival after transcatheter mitral valve replacement using a unique mitral valved stent design and anchoring system. METHODS: The new nitinol self-expandable valved stent houses a trileaflet glutaraldehyde-preserved bioprosthesis and contains atrial and ventricular fixation systems. Eight pigs underwent transesophageal echocardiogram-guided transapical mitral valved stent implantation through a lower mini-sternotomy. Intracardiac pressure gradients were estimated by transesophageal echocardiogram. RESULTS: The mean mitral annulus size was 24.6 +/- 1.4 mm, and the valved stent size was 26.0 +/- 2.6 mm. The average mean transvalvular gradient across the valved stent immediately after deployment, at 6 hours, and after 1 week remained low. The gradient across the neighboring left ventricular outflow tract was not affected. Average animal survival was 7.3 days (8 hours to 29 days). Animals that died before 1 week (n = 4) were found at necropsy to have valved stent malpositioning. Animals that survived 1 week or more had accurate deployment and only trace post-deployment paravalvular leak. The causes of death in this latter group were endocarditis (n = 1), failure of atrial fixation (n = 2), and failure of ventricular fixation (n = 1). There was no valved stent embolization in any of the animals. CONCLUSION: Adequate function and effective anchoring of the new mitral valved stent allowed for short-term animal survival after transapical mitral valved stent implantation.

The potential of cardiac allografts from donors after cardiac death at the University of Wisconsin Organ Procurement Organization.

OBJECTIVE: The purpose of this study is to investigate the potential availability of hearts from adult donation after cardiac death (DCD) donors within an acceptable hypoxic period. METHODS: We retrospectively reviewed a donor database from the University of Wisconsin Organ Procurement Organization Donor Tracking System between 2004 and 2006. The DCD population (n=78) was screened using our inclusion criteria for DCD cardiac donor suitability, including warm ischaemic time (WIT) limit of 30 min. In the same period, 70 hearts were donated from brain-dead donors. RESULTS: Of 78 DCD donors, 12 (15%) met our proposed DCD cardiac donor criteria. The mean WIT of these 12 DCD donors was 21 min (range 14-29 min). When inclusion criteria are further narrowed to (1) age <30 years, (2) WIT <20 min and (3) male gender, only two out of 12 met the criteria. CONCLUSIONS: Based on our proposed DCD cardiac donor criteria, the potential application of DCD cardiac donors would represent an increase in cardiac donation of 17% (12/70) during the 3-year period. When the criteria were narrowed to the initial 'ideal' case, only two donors met such criteria, suggesting that such 'ideal' DCD donors are rare but they do exist.

Strategies for left ventricular assist device insertion after the Dor procedure.

Insertion of the inflow cannula of an implantable left ventricular assist device (LVAD) is a surgical challenge in patients who have previously undergone a Dor ventriculoplasty procedure. We report a 54-year-old man who had successful LVAD insertion 18 months after a Dor procedure. We also describe the strategy of LVAD insertion in such patients.

The impact of the lung allocation scoring system at the single national Veterans Affairs Hospital lung transplantation program.

OBJECTIVE: The lung allocation score (LAS) has changed the distribution of donor lungs for transplantation. This study was undertaken to evaluate the impact of the LAS on a unique patient population undergoing lung transplantation (LTX) at the single national Veterans Affairs (VA) LT center. METHODS: One hundred and ten consecutive VA patients underwent LTX between 1994 and 2007. Patients transplanted using the LAS (LAS, n=26) were compared to patients transplanted prior to introduction of the LAS (pre-LAS, n=84). RESULTS: Waiting time decreased from 353.8+/-254.7 (pre-LAS) to 238.0+/-306.6 (LAS) days (p<0.01). Recipient diagnoses have changed with an increase in idiopathic pulmonary fibrosis [11% (9/84) pre-LAS vs 46% (12/26) LAS, p<0.01] and a decrease in emphysema [57% (48/84) pre-LAS vs 35% (9/26) LAS, p<0.01]. Mean LAS calculation was 33.1+/-2.9 for pre-LAS versus 41.9+/-9.8 for the LAS (p<0.01). Postoperative complications did not differ between the groups. Length of hospital stay decreased from 44.3+/-42.9 (pre-LAS) to 18.1+/-12.3 (LAS) days (p<0.01). Hospital mortality and 1-year survival did not differ between the pre-LAS and LAS groups (7% vs 8%; p=0.72 and 92% [95% confidence interval (CI) 86-98] vs 92% [CI 82-100]; p=0.23, respectively). CONCLUSIONS: The LAS appears to be achieving its objectives by reducing waitlist time and altering the distribution of lung disease being transplanted on the basis of medical necessity in the U.S. VA population. In addition, the LAS does not appear to have adversely affected short-term post-transplant outcomes in our recipient cohort.

Off-pump transapical mitral valve replacement.

OBJECTIVE: Percutaneous valve replacement was recently introduced, and reports of early clinical experience have already been published. To date, this technique is limited to the replacement of pulmonary and aortic valves in a strictly selected group of patients. The aim of this study was to analyse a self-expanding valved stent for minimally invasive replacement of the mitral valve in animals. METHODS: A newly designed nitinol stent was specially designed for this experimental acute study. It comprised of a left ventricular tubular stent with star shaped left atrial anchoring springs and carried a trileaflet bovine pericardial valve. A polytetrafluoroethylene membrane was sutured to envelop the atrial springs and the outside of the ventricular stent. The ventricular anchoring system was the same as in our previously reported results with a similar mitral valved stent. Seven pigs underwent minimally invasive off-pump mitral valved stent implantation. This was performed through a lower mini-sternotomy and a standard transapical approach under transoesophageal echocardiographic (TEE) guidance was used. RESULTS: The valved stent is fully retrievable and precise deployment and accurate adjustment of its intra-annular position is achievable to eliminate paravalvular leakage. The deployment time ranged from 127 to 255s and the blood loss from 70 to 220cc. One animal died of intractable ventricular fibrillation. Mitral regurgitation in all surviving animals was minimal (trace in 5/6 and mild in 1/6 during echo examination; on the contrast ventriculogram no mitral insufficiency was observed except in one documented as mild paravalvular regurgitation). These animals remained haemodynamically stable (6/6) and without TEE or ventriculographic changes for 1h. CONCLUSION: Implantation of a tricuspid bovine pericardial valved stent in the mitral position is feasible in pigs through a transcatheter approach. This was possible through a smaller delivery system than previously reported. Additional studies are required to demonstrate long-term feasibility, durability, and heart function.

Multidisciplinary approach decreases length of stay and reduces cost for ventricular assist device therapy.

High implantation costs and long postoperative length of stay (LOS) in debilitated patients complicate ventricular assist device (VAD) therapy. Between July 2000 and February 2005, 30 patients received a VAD at our institution. Of those, 20 patients were successfully discharged from the hospital with VADs. In August 2003, a multidisciplinary team was formed consisting of all services for VAD patients to replace a single-discipline (cardiac surgery) system. This team evaluated potential VAD candidates and identified optimal timing for implantation. These 20 VAD patients were divided into two groups according to the initiation of multidisciplinary team; the traditional group (n=7, July 2000-July 2003) and the multidisciplinary group (n=13, August 2003-February 2005). Patient demographics were not different. The LOS decreased from 61 to 15 days (P<0.01), especially LOS on the floor decreased from 35 to 7 days (P=0.03). The floor cost was significantly reduced ($47,111 vs. $8742, P<0.01), leading to a decrease in total postoperative cost ($202,238 vs. $161,744, P<0.01). The 30-day readmission rate decreased (5/7 patients vs. 1/13 patients, P<0.01). A multidisciplinary approach significantly decreased LOS and cost after VAD therapy, mostly by decreasing the cost of routine non-ICU care, without increasing the readmission rate.

Redo lung transplantation for acute and chronic lung allograft failure: long-term follow-up in a single center.

OBJECTIVE: This study was undertaken to evaluate outcomes of redo lung transplantation (LT) for acute and chronic graft failure. METHODS: Between 1988 and 2007, 388 LT procedures were performed on 369 patients. From those, 17 (4.6%) patients had redo LT once and 2 patients had redo LT twice. Patient survival and recurrence of bronchiolitis obliterans syndrome (BOS) after redo LT were reviewed. RESULTS: The overall survival rates of the 17 redo LT recipients at 1, 2 and 5 years were 59+/-23%, 59+/-23% and 42+/-25%, respectively. For the chronic graft failure group (n=12), survival rates at 1, 2 and 5 years were 67+/-26%, 67+/-26% and 44+/-30%, respectively. These survival rates were significantly lower than the survival rates observed in our experience after primary LT (n=352, 1-, 2- and 5-year survival rates of 88+/-4%, 80+/-4% and 65+/-5%, respectively. For the acute graft failure group (n=5), the 1-year survival rate was 40%; two patients remain free from BOS. Two patients had a second redo LT, one died from multi-organ failure on postoperative day 86 and the other died from pulmonary aspergillosis on postoperative day 214. CONCLUSIONS: Redo LT is a valid therapeutic option for selected patients with BOS and might be an option for highly selected patients with acute lung graft failure. Outcomes from a second redo LT are poor, and a second lung retransplantation must be used very cautiously, if at all.

Transapical mitral valved stent implantation.

BACKGROUND: Transcatheter aortic and pulmonary valve replacement is currently being tested in human trials. Efforts to create a valved stent to replace the atrioventricular valves have shown limited success. This is due to their their complex anatomy and function. METHODS: A self-expanding valved stent was created for transapical replacement of the atrioventricular valve. Ten pigs underwent transapical off-pump mitral valved stent implantation. Data were gathered to assess the animals' hemodynamic stability for 60 minutes after implantation. The valved stent function was assessed by transesophageal echocardiography (TEE) and contrast left ventriculogram. RESULTS: All animals exhibited normal hemodynamics immediately after mitral valved stent implantation and maintained stability for the entire period of monitoring. Accurate positioning of the valved stent was established in all animals. Mild paravalvular regurgitation was found in three out of ten animals by TEE and in two animals during left ventriculogram. No left ventricular outflow tract obstruction was encountered. CONCLUSIONS: Transapical off-pump mitral valved stent implantation is feasible in an acute experimental setting. Long-term function of the new valved stent remains to be established.

Improved survival in patients with ventricular assist device therapy: the University of Wisconsin experience.

OBJECTIVE: Ventricular assist devices (VADs) have been implanted since 1990 in our institution, becoming an increasingly common treatment for end-stage heart failure. Beginning in 1997, VAD patients were discharged home when feasible. In August 2003, a dedicated multidisciplinary VAD team (cardiac surgeons, cardiologists, VAD coordinators, nurses, rehabilitation specialists, nutrition experts, psychologists, pharmacists, social workers, and administrators) was created to optimize the management of VAD patients. The purpose of this study is to analyze the impact of these changes in care at our center over the last 17 years. METHODS: We retrospectively studied 107 consecutive VAD recipients between June 1990 and August 2006. VADs were implanted as bridge to recovery, bridge to transplant and destination therapy. The cohort was divided by care plans into early (n=37, June 1990-1996), mid (n=32, 1997-July 2003), and late groups (n=38, August 2003-August 2006). Demographic profile, survival and complications were assessed. RESULTS: Patient demographics tended to show an increased severity of illness over time. Post-VAD survival rate significantly improved in the late group (post-VAD 1- and 3-year survival rates; early: 54.1% and 40.5%; mid: 51.6% and 41.9%; late: 86.8% and 82.5%, p<0.001, respectively). The incidence of complications including re-operation, major bleeding and major infection, significantly decreased in the late group (p<0.05). CONCLUSIONS: Outcomes have improved dramatically in recent VAD patients, despite an increasingly high-risk patient population. These data suggest that advances in device technology and medical therapies, as well as a multidisciplinary approach, have improved survival on VAD therapy.

A novel use of the implantable ventricular assist device for isolated right heart failure.

Isolated right heart failure after cardiac surgery is uncommon and the prognosis remains poor. Additionally, managements for these patients are difficult. Profound postcardiotomy right heart failure developed in a 45-year-old woman after aortic root replacement for critical aortic stenosis with small aortic root. Although maximum medical therapy, intraaortic balloon counterpulsation and extracorporeal membrane oxygenator were attempted, severe right heart failure remained. Finally, an implantable right ventricular assist device (RVAD) was utilized because an immediate myocardial recovery was unlikely. The patient was discharged from the hospital at 17 days after the RVAD implantation. After 79 days of support, right ventricular function had recovered, the fully rehabilitated patient was successfully weaned from the RVAD, and the RVAD was explanted. The patient has no recurrence of heart failure 668 days after RVAD explantation.