Postinfarct refractory right ventricle: right ventricular exclusion. A possible option to mechanical cardiac support, in patients unsuitable for heart transplant.
BACKGROUND
Postbypass refractory right ventricle (RRV) may develop due to right ventricular (RV) ischemia or infarction. In cases with RV infarction, recovery is often prolonged and salvage rate is extremely poor. In this retrospective study, we have examined the role of right ventricular exclusion (RVE), as a possible option to conventional weaning or bridging to heart transplant (B-HTX), in patients who were unsuitable for heart transplant.


METHODS
During last 5 years, cumulative incidence of postbypass refractory circulatory failure (RCF) in our adult patients was 0.39% (26/6542). This problem was caused by a RRV in 17 (65%) patients. After CABG, these patients developed a grossly distended and poorly contracting RV (RVEDV: 330-400 ml, RVEF: 0-10%), high central venous pressure (> or =18 mmHg) and an inadequate aortic pressure for weaning off cardiopulmonary bypass. Three patients, who were unacceptable for HTX under UNOS program (age >65 years), were weaned off bypass after RVE, and remaining patients with RVAD (n=3) or BiVAD support, depending upon their concomitant moderate or poor left ventricular performance.


RESULTS
The significant predictors of RRV by univariate analysis were; 2nd or 3rd redo CABG for a recent myocardial infarction, and failed graft angioplasty. Hospital mortality (14-60 days) was 0/3, 3/3 and 3/11 for the patients weaned off with RVE, RVAD and BiVAD respectively. At 3 years, overall salvage rate was 9/17 (RVE: 3/3, BiVAD B-HTX 4/6 + 2 weaned with BiVAD support).


CONCLUSIONS
Right ventricular exclusion is a possible option to conventional B-HTX with mechanical support, in patients who develop postinfarct RRV and are unsuitable for transplant.
Kaul
T K
TK
Department of Cardiac Surgery, Baptist Medical Center, Birmingham, Alabama, USA.
Kahn
D R
DR
D000328:Adult; D000368:Aged; D002315:Cardiopulmonary Bypass / Q000379:methods; D000075202:Contraindications; D001026:Coronary Artery Bypass / Q000009:adverse effects; D018610:Heart Bypass, Right; D006333:Heart Failure / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D016027:Heart Transplantation; D006353:Heart-Assist Devices; D006801:Humans; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D012189:Retrospective Studies; D013318:Stroke Volume; D018497:Ventricular Dysfunction, Right / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D020257:Ventricular Remodeling / Q000502:physiology*