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THE JOURNAL OF CARDIOVASCULAR SURGERY

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The Journal of Cardiovascular Surgery 2000 June;41(3):349-55

Copyright © 2009 EDIZIONI MINERVA MEDICA

lingua: Inglese

Postinfarct refractory right ventricle: right ventricular exclusion. A possible option to mechanical cardiac support, in patients unsuitable for heart transplant

Kaul T. K., Kahn D. R.

From the Department of Cardiac Surgery Baptist Medical Center, Birmingham, Alabama, USA


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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 (≥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).
Con­clu­sion. ­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.

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