Right atriotomy closure with modified ventricular assist device ring.

BACKGROUND: Severe tricuspid regurgitation is a known risk factor for right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation and is often treated with concomitant tricuspid valve repair (TVR). The right atriotomy needed for exposure of the tricuspid valve may complicate early implantation of a durable right ventricular assist device, which may be needed if RVF persists. MATERIALS & METHODS: A 53-year-old male patient on Impella and extracorporeal life support was scheduled for LVAD implantation with concomitant TVR. RESULTS: We performed a technique for closure of the right atrium after TVR with a modified ventricular assist device ring to facilitate right ventricular support implantation if needed.

Single arterial access ECMELLA: A new concept and step-by-step procedure.

Therapy for cardiogenic shock using temporary mechanical circulatory support has improved significantly in the last decades, providing patients with new technologies for both acute phase stabilization and bridging to long-term therapies. A combination of a venoarterial extracorporeal life support system and the Impella left ventricular assist device (known as the ECMELLA approach) represents an effective therapy for severe cardiogenic shock that achieves high-flow circulatory support with simultaneous left-ventricular unloading. We present the new ECMELLA 2.0 concept, whereby a single arterial access technique is used to treat severe cardiogenic shock. The goal of this technique is to reduce access-related complications and make a bedside staged weaning from mechanical support possible.

ECMELLA 2.0: Single Arterial Access Technique for a Staged Approach in Cardiogenic Shock.

The main drawbacks of venoarterial extracorporeal life support (VA-ECLS) for cardiogenic shock are incomplete left ventricular unloading with concomitant pulmonary edema and vascular access site complications. We describe the staged treatment technique for severe cardiogenic shock with a combination of the Impella 5.0/5.5 (Abiomed Inc, Danvers, MA) and peripheral ECLS (ECMELLA) using a single arterial access in 2 consecutive patients with refinement of the technique in the second case. The arterial cannula was inserted through the same vascular graft in the axillary artery that served as access for the previously implanted microaxial blood pump.

Externalized conductor of a Kentrox lead and an unexpected insulation failure.

Cardiac resynchronization therapy-defibrillator device upgrades may represent a challenging scenario, especially because unexpected findings can increase procedure difficulty. One such unexpected finding represents insulation failure with unremarkable device interrogation. Insulation failure due to an externalized conductor of an implantable cardiac defibrillator-lead has been recently described for the Kentrox lead (Biotronik). Another challenging aspect of device upgrades is the presence of venous thrombosis as in this case. Here, we report an inside-out abrasion of a Kentrox lead, an unexpected second insulation failure found during pocket revision and the successful recanalization in a patient with known left subclavian vein thrombosis.

Two implantable continuous-flow ventricular assist devices in a biventricular configuration: technique and results.

OBJECTIVES: No continuous-flow right ventricular assist device for long-term support is available at the moment. Two continuous-flow ventricular assist devices used in a continuous-flow biventricular assist device configuration is an emerging option which has proven its feasibility but still is not approved for routine use. We present our technique and results of modifying the left ventricular assist device and making it suitable for right ventricular support. METHODS: Between September 2009 and October 2017, 39 patients received implantation of a continuous-flow ventricular assist device for right ventricular support in a continuous-flow biventricular assist device configuration. For implantation of the HeartWare® manufacturers name of the pump HeartWare HVAD pump (HVAD)® centrifugal ventricular assist device, we performed 2 major modifications: banding of the outflow graft and reducing the intracaval length of the inflow cannula. The HVAD® could be safely implanted into the right atrium or ventricle. The HeartMate 3® left ventricular assist device needed no banding, but we increased the extraventricular part of the inflow cannula. RESULTS: The overall 30-day survival for the group receiving primarily a continuous-flow biventricular assist device was 72.7% (9.5% standard error of the mean (SEM)), and the 1-year survival was 45.0% (10.7% SEM). The overall 30-day survival for the group receiving a subsequent pump for right ventricular support in a continuous-flow biventricular assist device configuration after temporary right ventricular support was 71.4% (12.1% SEM), and 1-year survival was 40.8% (13.6% SEM). CONCLUSIONS: At the moment, there is a lack of a continuous-flow right ventricular assist device especially designed and approved for right ventricular support. Therefore, modifications in continuous-flow ventricular assist devices designed for the left ventricle are done to make them suitable for right ventricular support. However, more information is needed regarding the optimal surgical technique, patient selection and the optimal time point of implantation.